WESTMINSTER CITY COUNCIL
Protocol 2015
Supporting adults with hoarding and selfneglect behaviours
A co-ordinated approach
Step by step best practice guide
Westminster Adult Social Care
City West Homes
Central and North West London NHS Foundation Trust
Central London Community Healthcare NHS Trust
Environmental Health
London Fire Brigade
The self-neglect and hoarding policy has been developed by and is shared with the Royal
Borough of Kensington and Chelsea
Policy
Introduction
Aims and Objectives of the Protocol
Principles of Effective Working
Definitions
Child Protection
Balancing Rights and Risks and the Mental Capacity Act 2005
Information Sharing
Resolution of Disagreements
Procedures
Referral and Responses
Assessment of the self-neglect/hoarding for the Panel
The Self-neglect/ Hoarding Panel
Monitoring and Review of the Protocol
Step by Step Flow Chart
Appendix 1 -Alert/Referral form
Appendix 2- Risk Assessment
Appendix 3- Panel Agenda
Appendix 4- Legal Table
Appendix 5- Useful Information
POLICY
1.0 Introduction
1.1 Managing the balance between protecting adults at risk from self-neglect or hoarding
behaviours against their right to self-determination is a serious challenge for services.
Working with people who are difficult to engage can be exceptionally time consuming
and stressful for all concerned. A failure to engage with people who are not looking
after themselves, whether they have mental capacity or not, can have serious
implications for the health and well-being of the person concerned and risk of
reputational damage to the local authority or health agencies involved.
1.2 Self-neglect and hoarding behaviours can also put neighbours, family and animals at
risk of harm with the risk of fires, gas and water leaks and infestations spreading.
1.3 This protocol offers guidance to operational staff and managers on how the needs or
presenting problems of difficult to engage adults who hoard or self-neglect should be
addressed. It suggests multi-agency partnership working to determine the most
favourable approach for achieving engagement with the adult. This is in conjunction
with a support plan for delivering the agreed goals and achieve the best outcome or
solution.
1.4 The Care Act 2014 came into force in April 2015. The Act fundamentally reforms how
the law works, prioritising people’s wellbeing, needs and goals so that individuals will
no longer feel like they are battling against the system to get the care and support
they need.
1.5 It highlights the importance of preventing and reducing needs, and putting people in
control of their care and support. An assessment must be person centred, involving
the individual and any carer that the adult has, or any other person they might want
involved. Looking forward this protocol has been developed with these principles in
mind.
1.6 In the majority of cases, the Community Care Assessment/Care Programme
Approach, review and risk assessment procedures should be the route to provide an
appropriate intervention in situations of self-neglect or hoarding. This is particularly
where the person engages with support offered and effective interventions to reduce
the risks are established.
1.7 Often, the cases that give rise to the most concern are those where an adult refuses
help and services and is seen to be at grave risk as a result. If an agency is satisfied
that the adult has the mental capacity to make an informed decision on the issues
raised, then that person has the right to make their own choices. But, this should not
be seen as ‘an all or nothing’ strategy. It is in these circumstances staff need to follow
the principles and procedures in this protocol.
1.8 With reference to the Pan London Safeguarding Adults multi-agency Policy and
Procedures1, it is important to remember that self-neglect on the part of an adult at
risk will not usually lead to the initiation of safeguarding adult procedures unless the
situation involves a significant act of commission or omission by someone else with
established responsibility for an adult’s care.
1
Protecting Adults at Risk: London multi-agency Policy and Procedures 2011 SCIE Report 39
1.9 The lead coordinating agency for managing cases of self-neglect or hoarding will have
responsibility to:
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Ensure the engagement of all appropriate agencies in responding to the
referral and the ongoing work.
Coordinate a response to Hoarding or self-neglect referrals
Manage the Self-neglect and Hoarding Panel
Reach a decision as to whether using the available legislation is an
appropriate course of action.
Plan and co-ordinate further actions including, inspection, cleaning, repairs
and possible re-housing or temporary accommodation options in
collaboration with the appropriate agencies/departments
2.0 Aims and Objectives of the Protocol
2.1 This protocol provides a framework of intervention drawing on best practice
approaches with reference to the legal context to prevent adults who self-neglect or
hoard coming to harm as a result. This includes an escalation procedure to a multiagency Hoarding and Self-neglect Panel.
2.2 Hoarding and self-neglect behaviours are not the same and do not always present
together. However there are often similarities in terms of health and social issues e.g.
isolation of the individual and lack of engagement with services that can present a
real challenge to practitioners where there is ongoing and significant risk of harm.
With this in mind this protocol has been developed to provide support to practitioners
in the engagement of the service user and the management of risk.
2.3 Referrals into the panel will apply where an adult has been identified as
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self-neglecting or where hoarding behaviours have put them or others at risk
which could result in significant harm and
the shared multi-agency approach has not been able to mitigate the risk of
significant harm.
2.4 See APPENDIX 2 for the hoarding and self-neglect risk assessment form. A score of
moderate or above would indicate the need for a referral to the panel.
3.0 Training
3.1 Member agencies are to encourage all levels of staff to participate in the multi-agency
self-neglect and hoarding awareness training provided under the Tri-borough Learning
and Development Programme to ensure a consistent and effective response when
formal complaints concerns or anxieties have been raised.
4.0 Principles of Effective Working
4.1 Whilst it has been recognised that self-neglect is not managed under the adult
safeguarding procedures, the same principles that apply to safeguarding will apply to
self-neglect or hoarding cases; there will be a multi-agency response to the concerns
raised. It is recognised that the sheer complexity of the multiple causes that may be
at play in any given case of hoarding or self-neglect renders a multi-agency strategy
indispensable. Central North West London Mental Health Foundation Trust (CNWL)
provides the care management functions on behalf of the local authority to adults with
mental health needs under the section 75 agreement. The Trust will therefore also
take the lead coordinating role on such cases where mental health is the main
presenting need of the adult at risk.
4.2 If concerns relate to acceptance of health care or treatment, the Adult Safeguarding
Lead for the Clinical Commissioning Group2 must be informed, regardless of whether
the case is being considered under safeguarding procedures.
4.3 There is an expectation that all professionals and agencies engage in full partnership
working to achieve the best outcome for the adult who chooses to hoard or selfneglect whilst satisfying organisational responsibilities and duty of care. The focus
should be on person centred engagement and risk management.
4.4 Risk assessment and risk management should be seen as an essential part of the
process when there are concerns. Arrangements should be made for monitoring and
where appropriate, making proactive contact to ensure that the adult’s needs and
rights are fully considered in the event of any changed circumstances. There is a need
to be mindful that organisational and professional risk aversion can hinder choice,
control
and
independent
living.
This
poses
real
challenges
for
practitioners/professionals in balancing risk enablement with their professional duty
of care to keep people safe. Risk enablement therefore needs to become a core part
of placing people at the centre of their own care and support.
4.5 It is important that all staff are familiar with, and are mindful of their ‘Duty of Care’
when dealing with cases of self-neglect or hoarding, even if the person has mental
capacity to make decisions specifically related to their care.
4.6 ‘Duty of Care’ can be summarised as ‘the obligation to exercise a level of care towards
an individual, as is reasonable in all circumstances, by taking into account the
potential harm that may reasonably be caused to that individual or his property’. Any
failure in the duty of care that results in harm could lead to a claim of negligence and
consequent damages.
4.7 Staff also need to be aware of service users rights in law and of the duties and
responsibilities of the council. A summary of these can be found in Appendix 4.
4.8 This guidance provides greater focus on those individuals deemed to have
mental capacity but when presented with the risks or statutory actions that may
be taken, refuses to engage in solutions to resolve the presenting problems. In
such cases, the individual chooses to live in a situation that places themselves and
potentially others at risk of harm. This will often require a professional judgement.
Such situations might include:
2
Clinical commissioning groups (CCGs) are NHS organisations set up by the Health and Social Care Act 2012 to
organise the delivery of NHS services in England- West London CCG covers Kensington and Chelsea and north
Westminster. Information can be found at http://www.westlondonccg.nhs.uk

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Portraying eccentric behaviours/lifestyles, such as hoarding or antisocial
behaviour causing social isolation. This can impact on the living environment
causing health and safety concerns
Neglecting household maintenance, and therefore creating hazards and
risking their tenancy.
Poor diet and nutrition, evidenced for example by little or no fresh food,
or what there is being mouldy or unfit for consumption
Refusing to allow access to health and/or social care staff in relation to
personal hygiene and care
Lack of personal or domestic hygiene that exacerbates a medical condition
that could lead to a serious health problem
5.0 Definitions
5.1 It is important that staff be familiar with, and recognise the risk factors associated with
self-neglect or hoarding. Often age related changes will result in functional decline;
cognitive impairment; frailty or psychiatric illness will increase vulnerability for abuse,
neglect and self-neglect as well as increase the potential for developing a number of
underlying health conditions
What is Self-neglect?
5.2 The complexity and multi-dimensional nature of self-neglect means that it can often
be difficult to support or protect the adult at risk. Staff must accept a person’s
autonomy and their right to make lifestyle choices and refuse services if they maintain
the mental capacity to make such choices.
5.3 Braye, Orr and Preston Shoot3 refer to the fact that self-neglect could have complex
causes and manifestation but there is no certainty of understanding about how the
range of factors involved might lead to particular behaviours or be amenable to
interventions. What is clear is that whilst researchers have sought to isolate factors
they have been unable to identify clear causation.
5.4 Complex dilemmas arise when people appear to choose rationally or intentionally to
self-neglect. In such cases there are often clinical, social and ethical decisions to be
made in its management. A review of literature suggests the following definition for
self-neglect:
• Persistent inattention to personal hygiene and/or environment
• Repeated refusal of some/all indicated services which can reasonably be
expected to improve quality of life
• Self endangerment through the manifestation of unsafe behaviours
5.5 SCIE produced some helpful guidance4. It states:
At one end of the spectrum, self-neglect is seen as a psycho-medical condition, in
some cases a psychiatric syndrome, which may be associated with other
accompanying mental disorders. Others take issue with a disease model of selfneglect, preferring to adopt a socio-cultural model which at its extreme sees self3
Conceptualising and Responding to Self-neglect: the challenges for adult safeguarding’- Journal of Adult Protection
2011 Vol 13 No 4-Suzie Braye, David Orr and Michael Preston Shoot
4 Self-neglect and Adult Safeguarding: Findings from Research 2011 SCIE Report 46
neglect as a social construct influenced by social, cultural and professional values, in
effect a value judgement as opposed to an objective phenomenon. In between lie
social psychological models that consider the interplay of factors external and internal
to the individual.
Research has sought to isolate factors, biological, behavioural and social, that may
be associated with, if not causative of, self-neglect, but without being able to integrate
the correlations within an overarching explanatory model. Models of self-neglect thus
encompass a complex interplay between mental, physical, social and environmental
factors. Executive dysfunction the inability to perform activities of daily living, even
though the need for them may be understood – is seen as significant, and when this
is accompanied by an inability to recognise unsafe living conditions, self-neglect may
be the result.
5.6 The research reveals that a strong emphasis is placed by practitioners on the
importance of interagency communication, collaboration and the sharing of risk.
What is Hoarding?
5.7 Compulsive hoarding is a specific type of behaviour marked by acquiring and failing
to dispose of a large number of items that would appear to have little or no value to
others, severe cluttering of the person's home so that it is no longer able to function
as a viable living space, and significant distress or impairment of work or social life.
5.8 It can be difficult to identify a person who hoards as the indicators are not always clear
and not all hoarders carry the same characteristics. Like most people, hoarders may
accumulate items for:



Sentimental value ‐ emotional attachment or to remember an important life event.
Utility value ‐ the item is or could be useful.
Visual value ‐ the item is considered to be attractive or beautiful.
5.9 However, the items kept by hoarders often differ from those kept by the general
population and the behaviour differs in extent. The issue may be ‘acquisition’ of
additional items or inability to discard existing items (including rubbish in some cases).
A case may be considered as hoarding, if for example “the clutter is so severe that it
prevents or precludes the use of living spaces for what they were designed for”.
5.10 In a case of hoarding, it often comes to the attention of professionals, housing
providers or statutory agencies when this behaviour begins to have an impact on the
person and/ or their neighbours. For example, where there is a health and safety risk,
neighbour nuisance, or obstruction of a landlord duty (e.g. to repair).
5.11 People who hoard often view their items as precious, or useful. They do not regard
their belongings as trash or rubbish, and the notion of downsizing their belongings
can illicit high levels of intolerable anxiety. In order to effectively work with people who
hoard it often necessitates working at a very slow rate, in order to slowly build up trust
and engagement.
5.12 It is essential therefore to build an understanding with the person regarding the
meaning of the collected items to the individual, and understand their perceived
barriers to organising and downsizing their belongings. Unfortunately however due to
lack of insight or motivation and high levels of risk, local authority and health agencies
are forced to intervene. Where this occurs, without the input and consent of the
service user, it is highly likely that following an enforced 'declutter' and 'deep clean',
the hoarding behaviour will continue, as the underlying cause of the hoarding, and
their inability to manage the hoarding has not been addressed.
5.13



Some hoarders manifest the following characteristics:
Isolated or extremely private individuals, often living alone;
Showing signs of self-neglect and/or ‘eccentric’ behaviour; and
Have experienced loss or trauma ‐ death of a close relative, separation or divorce,
redundancy or other serious life event.
5.14 However, many hoarders may be well‐presented to the outside world, appearing
to cope with other aspects of their life quite well, and giving no indication of what is
going on behind closed doors.
5.15
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5.16
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5.17
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Health implications can be:
Living in squalid conditions, infestations and associated diseases;
Limited cooking, bathing, heating. Sometimes without connected utilities ;
Self‐neglect, leading to other medical complications;
Lack of mental capacity leading to unwise decision‐making;
Anxiety and depression; and
Serious risk to life
Associated disorders may include:
Post-traumatic stress disorder (PTSD)
Obsessive–compulsive disorder (OCD)
Obsessive–compulsive personality disorder
Dementia
Depression and anxiety
Hoarding can be present in the absence of cognitive impairment or mental health
difficulties. It is also common for people who hoard to have difficulties making
decisions and to have poor organisational skills, which impede their ability to
address their hoarding.
Safety Implications
Risk of fire
Accidents in the home
Buried under items
Access for emergency services
Access for any professionals
6.0 Child Protection and other vulnerable adults
6.1 If a child is at risk due to the self-neglect or hoarding behaviours of the adult, then
engagement of the Pan London Child Protection Policy and Procedures5 is
essential.
6.2 There may also be other vulnerable or dependant adults living with the person who
are also put at risk by the behaviours of the person hoarding or self-neglecting.
7.0 Carers
7.1 For the first time carers will have the same rights as service users under the Care
Act 2014. In situations where a carer is supporting someone who self neglects or
has hoarding behaviours or indeed lives with the person then there are statutory
requirements coming into force.
7.2 Where an individual provides or intends to provide care for another adult, local
authorities must consider whether to carry out a carer’s assessment, if it appears
that the carer may have any level of needs for support.
7.3 Carers’ assessments must seek to establish the carer‘s need for support, and the
sustainability of the caring role itself – practical and emotional support. The local
authority must include a consideration of the carer’s potential future needs for care
and support.
7.4 Factored into this must be a consideration of whether the carer is currently able, and
whether the carer will continue to be able to care for the adult needing care. The
consideration of sustainability must also involve a consideration of whether the carer
is willing, and likely to continue to be willing, to provide care.
7.5 The carer’s assessment must also consider the carer’s activities beyond their caring
responsibilities and the impact of caring upon those activities. This impact should
be considered in the short and long term.
8.0 Balancing Rights and Risks and the Mental Capacity Act 2005
8.1 The nature of any intervention will centre on the question of whether the adult
concerned has the mental capacity to make decisions that have legal force. A person
may have mental capacity and yet disagree with the views of the local Social Services
authority- or other agency. The right to take what may be seen as a contrary view is
a right that can no longer be taken away from a person who has mental capacity to
make that decision. It does not preclude the local social services authority
entering into a discussion with the service user and exploring the basis for a
contrary view. It also does not preclude agencies working together to share
information in the vital interest 6 of the person and assess the risks even if the
person does not want any support.
8.2 It is important that staff accept the rights of service users to make lifestyle choices
and to refuse services. Critical to this however is assessing the decision-making
5
6
London Child Protection Procedures - 4th edition (Apr 2011)
Vital interest is a term used in the Data Protection Act 1998 to permit sharing of information where it is critical to prevent
serious harm or distress or in life threatening situations.
Mental Capacity of service users whilst taking account of the risks and safety
implications of the decisions being made.
8.3 The Mental Capacity Act 2005 states that there should always be a presumption of
capacity, unless the adult has been assessed and found to lack capacity for a
particular decision. Any assessment of mental capacity must be decision specific.
This means that a person may be able to make decisions about one aspect of their
life but may lack capacity in another. In cases of hoarding or self-neglect, capacity
should be assessed relating to particular decisions about refusal of support and care.
8.4 Staff must be aware of the 5 principles of the Mental Capacity Act:
1. Every adult has the right to make his or her own decisions and must be assumed
to have capacity to do so unless it is proved otherwise.
2. The right for individuals to be supported to make their own decisions ‐ people
must be given all appropriate help before anyone concludes that they cannot
make their own decisions.
3. Individuals must retain the right to make what might be seen as eccentric or
unwise decisions.
4. Best interests ‐ anything done for or on behalf of people without capacity must
be in their best interests.
5. Least restrictive intervention ‐ anything done for or on behalf of people without
capacity should be an option that is less restrictive of their basic rights and
freedoms of action‐ as long as it is in their best interests.
8.5 The assessment of Mental Capacity is a two stage test ‐ to check whether there is an
impairment of, or disturbance of the mind, sufficient to affect decisions, and then to
test whether it is affecting this particular decision. Where the initial mental capacity
test appears to indicate a lack of capacity, an initial assessment should be
documented using the core assessment tool7.
8.6 Capacity can be reassessed when appropriate, as an individual’s capacity may
change over time, in different circumstances and for different decisions. Where the
person has capacity they may still be offered or signposted to appropriate support.
8.7 It is recognised that establishing a positive relationship with service users is crucial in
gaining their trust. The professional judgement of staff can make a positive and
effective contribution to the early recognition and prevention of harm.
8.8 In regards to self-neglect, the literature makes a distinction between the adults ability
to self-care with that of making a lifestyle choice8. Assessment therefore needs to
tease out this distinction in order to identify the most appropriate support to the
individual.
8.9 There is also the matter of whether despite having mental capacity to make
decisions the adult has ‘executive capacity’9 to carry out the decision.
8
Conceptualising and Responding to Self-neglect: the challenges for adult safeguarding’- Journal of Adult Protection
2011 Vol 13 No 4-Suzie Braye, David Orr and Michael Preston Shoot
9 Executive dysfunction-the inability to perform activities of daily living even though the need for them may be understood
‘Where decision making capacity is not accompanied by executive capacity the
individual may not in fact be in a position to exercise autonomy and professional
intervention may appropriately take a different approach in order to safeguard
wellbeing’10
8.10 From a defensible practice point of view recording the rationale for decisions to
intervene or not intervene in any given situation is essential.
9.0 Information Sharing
9.1 The information-sharing protocol sets out the following guidance for sharing
information:
• sharing information with consent
• sharing information without consent
• sharing information when the person does not have capacity to consent
Sharing Information with Consent
9.2 Adults have a right to independence, choice and self-determination. This right
extends to them being able to have control over information about themselves and to
determine what information is shared. Even in situations where there is no legal
requirement to obtain written consent before sharing information, it is good practice
to do so.
Sharing Information without Consent
9.3 The Data Protection Act 1998 will allow the sharing of information without consent in
an adult’s vital interest.
9.4 Vital interest11 is a term used in the Data Protection Act 1998 to permit sharing of
information where it is critical to prevent serious harm or distress or in life threatening
situations.
9.5 If the adult at risk of self-neglect or hoarding behaviours has the mental capacity to
make informed decisions about their health and well-being and they do not consent
to a referral, this does not preclude the sharing of information under this protocol with
relevant professional colleagues.
9.6 This is to enable professionals to assess the risks and to be confident that the adult
is being fully supported and is aware of all the options. This will also enable
professionals to check the safety and validity of decisions made. It is good practice to
inform the adult at risk that this action is being taken unless doing so would increase
the risk of harm.
9.7 If the adult at risk has the mental capacity to make informed decisions about their
health and well-being and they do not consent to a referral being made or the
sharing of information but others may be at risk, practitioners have a duty to share
the information with relevant professionals to prevent harm to others.
10
Conceptualising and Responding to Self-neglect: the challenges for adult safeguarding’- Journal of Adult Protection
2011 Vol 13 No 4-Suzie Braye, David Orr and Michael Preston Shoot
11
Schedule’s 2 and 3 Data Protection Act 1998 outlines the conditions for sharing information fairly and lawfully.
Sharing information when the person does not have capacity to consent
9.8 If an adult at risk lacks capacity to make informed decisions about maintaining their
health and well- being and they do not consent to a referral under this policy,
professionals have a duty to share the information in their best interests under the
Mental Capacity Act 2005.
General Principles
9.9 The adult’s wishes should always be considered, however, supporting an adult at
risk from self-neglect or hoarding behaviours establishes a general principle that
concerns can be reported more widely and that in so doing, some information may
need to be shared among those involved.
9.10 An organisation should obtain the adult at risk’s consent to share information and
should routinely explain what information may be shared with other people or
organisations.
9.11 Difficulties in working within the principles of maintaining the confidentiality of an
adult should not lead to a failure to take action to support the adult in line with this
protocol.
9.12 Whether information is shared with or without the adult at risk’s consent, the
information shared should be:
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10.0
necessary for the purpose for which it is being shared
shared only with those who have a need for it
be accurate and up to date
be shared in a timely fashion
be shared accurately
be shared securely.
Engagement
10.1 One key to successful interventions with adults who are not engaging with
support on offer but remain at risk is to build a relationship with the individual that
allows their perspective to gradually unfold and that would inform decisions.
10.2 Respecting an adult’s independence does not and should not mean disengaging
from continued involvement with them. On-going commitment allows time for a fuller
assessment including decision making capacity to be monitored as well as allowing
options to emerge and possible acceptance of interventions over time.
10.3 In certain instances a more effective initial approach is to tackle the issues that
the adult has concerns about which might include health issues or lack of social
networks rather than just a focus on the self-neglect.
10.4 Fully informed multi-agency collaboration can help promote genuinely
independent choice while minimising threats to this choice. Paying attention
therefore to the range of available interventions in order to identify the least
restrictive options on offer should be a priority. Where all these ingredients are
present, it becomes possible to achieve the optimum balance between autonomy
and support.
10.5 Consideration should be given to invite the person who is self-neglecting or
hoarding to the panel. This may be one way to effectively engage the individual in
the issues.
11.0
Resolution of Disagreements and Complaints
Interagency
11.1 Any interagency disagreements about case management should be resolved
locally. As a last resort such disagreements can be brought to the panel for discussion.
Complaints
11.2
Complaints about specific cases that have been escalated to member level can
be signposted to the panel for a response.
PROCEDURES
12.0
Referral and responses
Referrals
Cases that are known
12.1 Referrals can come from a range of sources including from the person
themselves, neighbours, family or friends and referrals from other professionals.
12.2 All referrals made by external agencies will come via Westminster Adult’s Access
Service using the alert document SNHA1 (see appendix 1) where they will be
processed, entered on to Frameworki and sent to the appropriate Lead Agency.
12.3
The contact details are…
Tel: 020 7641 1175
Fax: 020 7 641 5426
E-mail: [email protected]
Secure e-mail: [email protected]
12.4 For cases that are open and being managed by Adult Social Care or the Mental
Health Trust, and the self-neglect or hoarding behaviours have worsened over time,
the management of such cases needs to be progressed in line with this protocol by
the allocated team.
Cases not known – criteria for Lead Agencies
12.5 Referrals for those cases that are not already known to Adult Social Care and are
presenting as below, will also be received into the Access team for screening.
Individuals who have the following needs will be passed to Adult Social Care who
will become the Lead Agency…
.
 Community Care needs
 Safeguarding
 Self- neglect
 Lack Mental Capacity
If none of the above apply then the most appropriate agency will take the lead. Please
see criteria below.
The criteria for referrals to be sent to Housing is:City West Homes will be the lead agency where:

there is a clear breach of tenancy conditions
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
the resident is not known to adult social services (or any other support agencies)
the resident is not considered vulnerable or have mental health issues
Environmental Health will be the lead agency where:-
Hoarding & Self-Neglect Protocol
Residential EH
Referral from Access Team, including case
information pack and Lead Agency details, sent
to REH Hoarding & Self Neglect Point of
Contact:
Ian Hennessy
[email protected]
LEAD
AGENCY
Case delegated to district EHO for
arrangement of Case Conference.
EHO examines case information pack.
NON-LEAD
AGENCY
Case delegated to district EHO for
attendance at Case Conference
EHO arranges and sends out Case
Conference invite to representatives
from partner agencies
Case conference held.
Attendees noted, minutes taken, and
agreed actions with timescales
recorded.
TSO to take minutes and circulate.
Follow up case conference diarised.
District EHO examines case
information pack before Case
Conference.
Attends Case Conference on behalf of
REH, and carried out any actions
assigned to REH
12.6 Some cases will be referred during the person’s hospital admission or
presentation in A&E or as an outpatient. These cases should also be signposted to
social services Access Team to be screened initially by the social services Access
Information and Advice Officers (IAO)
Adult Social Care Response
12.7 All referrals must be sent to the Adult’s Social Care Access Team with a copy of
a completed self-neglect/hoarding risk assessment form (see Appendix 2) the clutter
image rating tool (Appendix 2) indicating the level of the individuals hoard and a
completed self-neglect/hoarding risk assessment form. Access will complete a
referral and upload all documents on to Frameworki. Once a referral has been
completed by the Access team, the case with all documents will be forwarded to the
most appropriate lead agency (see criteria’s above – 12.5) for on-going engagement
and risk management as appropriate.
12.8 In many instances it would be beneficial for joint assessments to be conducted
with a mental health practitioner as accurate assessment of such cases can be
challenging. This may not result in on-going work from the mental health trust.
12.9 This referral path will ensure that all self-neglect/hoarding cases are dealt with in
a uniform way across all departments and by all partners of the Council.
Cases referred into Central North West London NHS Foundation Trust (CNWL)
12.10 Where joint assessment with mental health services is indicated, a referral
should be made to the Assessment and Brief Treatment Team (ABT). If, following a
mental health assessment, the person is identified as being at low risk according to
The Self Neglect/Hoarding Risk Assessment decision grid, ABT will provide
short term interventions (up to a maximum of six sessions) to that individual
according to assessed need.
2)
Where an individual has been assessed by ABT and has been identified as being
at moderate or severe risk as per the Self Neglect/Hoarding Risk Assessment
decision grid, ABT will attend the Self Neglect/Hoarding panel.
3)
Should the panel decide that ongoing interventions from Mental Health Services is
required, people with longstanding secondary care MH needs will be referred to
other MH services.
4) All teams need to be briefed on the final protocol and understand their working
relationships with RBK&C Adult Care Teams.
Feeding Back to the Referrer
12.11 Concerns about people who hoard or self-neglect often carry high levels of public
and professional anxiety. It is important therefore for the Lead Agency to feedback to
the referrer on a need to know basis what the response to the referral is.
13.0
Assessment and multi-agency meetings
13.1 Before escalation to the hoarding and self-neglect panel, an assessment of need
will be completed and a series of multi-agency meetings will be convened and
coordinated by the Lead Agency. It may be appropriate to have a senior member
of staff chairing that meeting or in attendance. All relevant agencies need to be
considered to be invited e.g. Adult Services, Environmental Health, London Fire
Brigade, Mental Health Trust, Community Health Services, Housing, Police TMO etc.
This is to ensure a wide range of professional views are obtained and intelligence is
shared. The individual must also be invited to attend and contribute towards these
meetings.
13.2 The purpose of the meeting is to establish the assessed needs of the adult, the
level of risk to the individual and others, the person’s engagement or lack of with the
interventions, the decisions that need to be made and what the person’s mental
capacity is in relation to the decision e.g. to have a blitz clean, to accept services.
13.3 Establishing the mental capacity of the individual is a vital aspect of care
planning and risk assessment when working with an adult who is self-neglecting or
hoarding and refusing services, or where there are concerns about others making
decisions on their behalf. Capacity Assessments will need to be completed by Adult’s
Social Care or the MH Trust.
13.4 The assessment also needs to take into account the following factors which
would assist in determining a support plan




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
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






14.0
Physical health
Psychological state and mental health- e.g. depression
Personality traits
Functional and cognitive abilities
Nutritional intake
Social networks
Ability to perform activities of daily living
Social and medical histories
Understanding the person’s perception of the situation and motivations
Risk assessment of the home and the individual
Historical perspective to inform whether the current situation derives from a life
pattern
Economic resources to the individual
Alcohol and/or substance abuse
Traumatic histories and life-changing events
The adult’s perceived self-sufficiency and receptiveness to support
Referrals to the Panel
14.1 There will be an expectation that a multi-agency strategy meeting and case
conferences have been held and actions taken to address risks prior to presentation
at panel. The panel will require copies of the minutes of these meetings; the clutter
score index; and risk assessments prior to a case being presented. The lead agency
completing the referral to panel will need to come to panel to present the case or
send a representative.
15.0
The Self-neglect/ Hoarding Panel
15.1
The panel is designed to complement and enhance the work that should already
be on going with a person deemed to be at moderate to high risk. Therefore it is
expected that multi-agency network meetings are convened, coordinated and led by
the Lead Agency prior to a referral to the panel. This is to ensure all options have
been explored including attempts to engage the individual.12
15.2 If following a case conference and risk assessment the person is still at moderate
to high risk of harm and the person may not be engaging or there is difficulty in
engaging other agencies, the case should be referred to the Hoarding/Self-neglect
Panel by the Lead Agency.
15.3 The Panel will discuss cases which have been presented to them with a view to
determining the next steps, particularly where cases are complex or have reached a
‘sticking point’ (i.e. such as access being denied) and organisations have exhausted
their internal procedures.
15.4 The Panel’s role is to provide guidance as well as enhance communication
between agencies, and assist with the coordination of cases where cross‐
organisational barriers may surround the case. The Panel will be expected to
consider any vulnerability or equality and diversity issues within their
recommendations.
15.5 The Panel will also review previously presented cases to establish if agreed
actions have been carried out and whether risks have been reduced.
15.6 The decision for a review date will be set by the Panel based on the level of risk
and the timescale for the agreed actions.
15.7 Panel members will be expected to share best practice or legal changes,
especially within their specified field, with the rest of the Panel. This knowledge will
also be shared with partner organisations who have signed up to the protocol.
15.8 The Panel is comprised of named representatives who hold a strategic role from
a range of agencies. The following services will be required to be represented at the
Panel meetings:

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



12
Environmental Health
Adult Social Care
Community Mental Health (AMHP), Assessment and Brief Treatment and
Recovery service lines, CMHT older adults
Housing
Community Health
London Fire Brigade
See ASC CM Guidelines for dealing with complex cases and/or/ ASC CM guidelines for working with people who hoard
or self-neglect.
15.9 In cases where lead officers cannot attend, it would be expected that a deputy
attends in their place.
15.10 In addition the panel may require the expertise of the following services at some
of the meetings:

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16.0
Metropolitan Police
Acute Health Services
Primary Care
Children & Young People’s service
Safeguarding lead
Voluntary Sector org
Pest Control
LAS
Psychology
Monitoring and Review of the Protocol
16.1 The steering group that is responsible for the development of this policy will meet
on a six monthly basis in order to monitor and review the implementation of this
protocol. The functions of this group would include:



To monitor the numbers of self-neglect and hoarding cases in RBKC
To ensure constructive partnership working for the continued implementation of
this guidance
To review and update this guidance annually
Step by Step Process flow chart once alert received
Self-neglect/hoarding alert, image clutter rating and
completed SNAH risk assessment are received &
further information gathered by Access Team.
Frameworki is completed.
Following the criteria, a Lead Agency is identified.
Follow Practitioner guidelines ‘Self neglect and
Hoarding guidance’
Lead Agency convenes a multi-agency meeting to
review risk, assess capacity to make relevant
decisions and agree an action plan.
Subsequent meetings are held to review progress on
actions and measure risk.
If the multi- agency strategy meetings and case conference
actions have not managed to reduce risk or improve the
situation for the individual, a referral is made to the Self
neglect/Hoarding Panel. The panel meeting brings together all
the relevant services. The meeting agrees actions which may
include formal intervention using legislation.
Date should be agreed by panel for the Lead Agency to
represent the case with updates on outcome of the agreed
interventions.
Actions agreed by the panel should be carried out with
continued multi-agency input and communication.
Lead Agency brings case back to panel on agreed date to give
feedback and agree any further actions.
Self-neglect/hoarding Alert Form (SNHA1)
Adult Social Care CONTACT DETAILS
Social Services Line’: 020 7361 3013
Emergency Duty Team: 020 7373 2227
Fax: 020 7368 0314 (office hours only)
Secure Email: [email protected]
Email: [email protected]
DETAILS OF SELF-NEGLECT/HOARDING CASE
NAME
Fi User ID
Address
DOB
AGE
USER GROUP
Learning Disability
Older People
Substance Misuse
ETHNIC ORIGIN
White British
White Traveller
of Irish Heritage
Black Caribbean
Indian
Chinese
White Irish
Mixed White
and Black
African
Other
Mixed White
and Asian
DATE & TIME OF
REFERRAL
TENURE
Home Owner
GENDER
Mental Health
Physical & Sensory
Other vulnerable people
Other White
White
Gypsy/Roma
Black African
Pakistani
Other Asian
Other Black
Bangladeshi
Mixed White
and Black Caribbean
Mixed White
and Chinese
DATE & TIME ALERT
REPORTED
Lease Holder
Council Tenant
Private rented
Housing Association Tenant
Temporary Accommodation
Other
SOURCE OF
REFERRAL
Appendix 1
Neighbour
GP
Estate Officer
Floating Support Worker
Social Worker/ Community Nurse
Police
Other
Hospital
DETAILS OF THE
PERSON
COMPLETING THIS
FORM
NAME
JOB TITLE /
PROFESSION
CONTACT DETAILS
DATE
DETAILS OF THE
TEAM MANAGER IF
OPEN TO A TEAM
NAME
JOB TITLE /
PROFESSION
CONTACT
DETAILS
DATE
APPENDIX 2
Self-neglect/Hoarding Risk Assessment Tool
Table 1-Likelihood
Descriptor
Almost certain
Likely
Possible
Unlikely
Rare
Description
Will probably occur frequently
Will probably occur frequently but not as a persistent issue
May occur
Not expected to occur
Would only occur in exceptional circumstances
Score
5
4
3
2
1
Table 2 Consequences
Level
5 =Catastrophic
Injury/risk of harm to service
user
Unanticipated death (by
fire?), multiple severe injury,
permanent disability, could
be caused by falling items or
result of non compliance with
medication or treatment.
Injury/risk of harm to
others
Severe infestation to
neighbours and
surrounding properties.
Development of pressure
areas grade 3 or above, lack
of continence management.
Inability to safely access
and use communal areas
due to clutter impinging
on these areas from
affected property.
Unable to use majority of
rooms, disconnection of all
utilities
Fire spreading from
affected property.
Cost to individual/and
others
Death, significant
deterioration in physical
and/ or mental health and
wellbeing, relapse to using
substances, total loss of
independence etc
Enforcement by
Environmental health which
will be charged to the
individual.
Severe odour in
communal areas
Eviction/ legal enforcement
by Environmental health and/
or housing.
Severe infestation that could
spread, causing infection or
injury
4 =Major
Severe odour
Major permanent loss of
function related to selfneglect, lack of compliance
with medical treatment.
Significant self-neglect
requiring hospitalisation,
Development of pressure
areas grade 2 or above, poor
continence managements
Limited safe access to
communal areas,
Infestation.
Moderate odour in
communal areas
Prolonged medical
admission, change to living
arrangements, total loss of
independence, impact on
physical and/or mental
health and well-being,
Severe infestation that could
spread
Unable to use most rooms,
lack of utilities
Non fatal fire
3=Moderate
Strong odour
One or more rooms unusable,
or use severely impaired by
level of clutter, this may
include rubbish.
Some items may increase risk
of severity of fire – such as
hoarded paper.
May be some small items
in communal area, but
not constantly.
Light odour in communal
areas.
psychological, anxiety,
depression as a reaction
requiring medical
intervention, pain and
discomfort, semipermanent, loss of
independence etc
Some loss to independence,
some level of selfneglect/non-compliance, i.e.
inconsistent engagement
with medical staff or
medication management.
2 =Minor
Poor engagement with
continence management but
some compliance
Small collections of items, not
rubbish and not causing
obstructions.
no real loss to independence
or level of function
Moderate level of
engagement with medication
and care,
1= Insignificant
Responds to relationship
building and rapport with
professionals.
Some small collections of
items, not impacting on use
of any rooms.
Engages fairly well with
support.
No loss of independence
Likelihood
Risk Assessment Decision Grid
Consequence
5
5
10
15
20
25
4
4
8
12
16
20
3
3
6
9
12
15
2
2
4
6
8
10
1
1
2
3
4
5
1
2
3
4
5
In the case of the 5x5 matrix, the action levels are:
15-25
5-12
1-4
HIGH RISK-Convene emergency multiagency network
meeting to agree actions and responsibilities and
referral to Panel
MODERATE RISK -Multi agency input required and
referral to Panel
LOW RISK-Liaise with other professionals, offer info to
Service User
Guidance on how to use the risk assessment decision tool
The primary aim of the Self-neglect/Hoarding Risk Assessment is to assess:
 individuals for the current risks that they face
 potential risks they may face
The secondary aim of the Self-neglect/Hoarding Risk Assessment is to assess:
 reasonably foreseeable risks to the individual from their behaviours
 reasonably foreseeable risks to the individual and other service users if safeguards or
improvements are not put in action to address their behaviours
Concept of risk
The aim of undertaking a risk assessment is to identify the hazards associated with a situation
and to assess the seriousness of these hazards. To then formulate a risk management plan to
reduce the associated risks to a minimum or at least to an acceptable level.
What is a hazard?
A hazard is anything with the potential to cause harm; every hazard has likelihood and a
consequence. A hazard can be absolutely anything – person, behaviour e.g. non engagement/
refusal of services, personality, object, illness, medical condition, disability impairment, incapacity,
addiction, dependency, environmental factor, or situation.
Risk is the likelihood that a hazard will cause a specified harm and usually qualified by some
statement of the severity of the harm or consequence.
Likelihood
This is a measure of the chance that the hazard will occur. Example of low likelihood is where a
person is engaging with the risk management plan and the risks are reduced. Example of a high
likelihood is where the person is fully capacious but is refusing to engage with services to reduce
the risks.
Consequence
This is the outcome of the hazard. It is assessed according to the impact the event had on the
person. A severely cluttered house occupied by a frequent smoker could result in catastrophic
consequence for the service user and others.
Likelihood
x
Consequence = RISK
The risk assessment uses a traffic light system with Green being universally used as safe to
move forward. Red signifies stop and Amber being preparing to stop. In this case Red means a
halt to hazardous activities needs to occur with immediate effect and safeguards put in place.
Amber signifies moving forward with caution which may mean modifying the risk with some
safeguards. Green means it is safe but also looking to be sure it is safe with a monitoring or
review plan.
Recording needs to be specific for example stating that the risk or danger may be physical harm
caused by falling over clutter. Risks or dangers might be: cuts, bruises, fractures. it might be
necessary to put death as a possible risk or danger. It is therefore exposure to a chance of loss or
injury.
Risk management strategies
There is an order of hierarchy of risk control that can be used to help decide on a risk control, with
risk control options at the top of the hierarchy being the best measure because it is much less
reliant on other variables doing something to allow the risk to persist. We can categorise risk
control measures as follows:
Reducing the hazard
This would mean reducing the impact of the person’s behaviour. A package of care may reduce
the amount of clutter to a safe level or support the person with their personal care which avoids
pressure areas or infection.
If a professional is able to build a rapport with the person then there may be better engagement
on managing the risks.
Capacity and advocacy
When identifying risks, one must take into consideration the mental capacity for decision making
of person/s at risk. Capacity issues highlight the level of control the vulnerable adult may have
over his/her current situation and his/her ability to make decisions relating to taking risks and
accepting support that might reduce the risks.
If the person is found not to have capacity and a best interest decision is required in regards to
their accommodation, one must ensure that the vulnerable person’s right to advocacy is upheld.
Where the vulnerable person is not represented or their family/carer may not be acting in their
best interests, an IMCA must be instructed to act as the advocate for the vulnerable adult.
* The risk assessment is not a definite science, it is a decision making support tool and
the risk score can change over any period of time or with different intervention*
Clutter Rating
Appendix 3
RBKC Hoarding Self-neglect Panel Agenda
1.
Introductions
2.
Case Presentation
3.
Recommended interventions-Roles, Responsibilities and Timescales
4.
Date for Review
5.
Cost and Responsibility for funding
6.
Any other business
APPENDIX 4
Please see powers available by various agencies
AGENCY
LEGAL POWER AND ACTION
Adult Social Care
Care Act 2014
Clause 1
Local authorities will have a general duty, when undertaking adult social
care functions with an individual, to promote their well-being.
Must have regard to:
 physical and mental health, emotional well-being and personal dignity
 protection from abuse and neglect
 control by the individual over day-to-day life (including over care and
support, or support, provided to the individual and the way in which it is
provided)
 participation in work, education, training or recreation
 social and economic well-being
 domestic, family and personal relationships
 Suitability of living accommodation
 the individual’s contribution to society
Clause 3
Local authorities must exercise its functions regarding adult social care with
a view to ensuring the integration of care and support provision with health
provision and health-related provision where it considers that this would,
among other things, promote the well-being of adults in its area.
Clause 7
Local authorities can request the co-operations of a relevant partner in
regards to specific cases, and vice-versa. The request must be complied
with unless it is “incompatible with its own duties” or “would otherwise
have an adverse effect on the exercise of its functions”. Written reasons
must be given for a decision not to comply with a request.
CIRCUMSTANCES REQUIRING
INTERVENTION
Councils have a legal duty to assess
needs where a concern has been raised
about a person’s health and well being.
Clauses 9 and 11
A local authority must assess a person’s needs for care and support unless
that person refuses an assessment. But an assessment cannot be refused,
and the local authority must carry it out, if the person lacks capacity to
refuse and carrying it out would be in their best interest, or the adult is
experiencing, or is at risk of, abuse or neglect.
Environmental Health
Section 83 Public Health Act 1936 Filthy /Unwholesome premises which are
prejudicial to health or verminous.
Service of Notice requiring clearance/cleansing/pest control treatment. No
appeal.
Environmental Health
Where hoarded materials result in filthy,
unwholesome or vermin infested
premises. This is often where there is a
lack of engagement or co-operation of
occupier.
Council has powers to enter premises by warrant if reasonable access not
given after giving notice. This will be to assess the conditions or carry out
works in default. Possible prosecution and Council can recover expenses
for works in default.
There must be likelihood of adverse
health effect to occupant or rodents or
insects present. There may also be
complaints from neighbours which must
be investigated by the Council.
Section 79/80 Environmental Protection Act 1990
Statutory Nuisances Service of Abatement Notice requiring action to remove
nuisance and/or prevent a recurrence.
Council has a legal duty to investigate
complaints of statutory nuisance and
must take action if nuisance proven.
Appeal against notice possible.
Possible prosecution and Council can recover expenses for works in
default.
The premises must be in such a state
that they are prejudicial to healthy or a
nuisance to neighbours. This may be
from condition of the premises,
accumulations, deposits or even animals
kept in unsanitary conditions.
Injunctive proceedings may be taken.
Intervention often prompted by
complaints from neighbours.
Warrant powers similar to above.
For exceptional situations where
widespread nuisance to neighbours
Environmental Health
Housing Act 2004
Housing hazards such as Domestic Hygiene, Pests and Vermin, Excess
Cold, Fire.
Service of Improvement or Hazard Awareness Notice usually on owner of
premises requiring building defects being rectified to reduce the hazards.
Council can charge for costs incurred serving notices.
Appeal provisions. Possible prosecution and Council can recover expenses
for works in default
Environmental Health
Prevention of Damage by Pests Act 1949 (section 4)
Service of Notice to keep land free from rats or mice
No warrant powers
Possible prosecution and Council can recover expenses for works in default
Metropolitan police
London Fire Brigade
Power of Entry – (S17 of Police and Criminal Evidence Act)
Person inside the property is not responding to outside contact and there is
evidence of danger.
Prohibition or Restriction of use (Regulatory Reform (Fire Safety)Order
2005)
The fire brigade can serve a prohibition or restriction notice to an occupier
which will take immediate effect. In some circumstances this can apply to
domestic premises including single private dwellings where the appropriate
criteria of risk to relevant persons apply.
Animal Welfare
agencies
such as RSPCA/Local
authority e.g.
Environmental
Animal Welfare Act 2006
Offences (Improvement notice)
Education for owner a preferred initial step, Improvement notice issued and
monitored, If not complied can lead to a fine or imprisonment
continues after intervention and usually
after service of notice.
Relates to possible health and safety
effects on occupier. Hoarding can lead
to fire hazards from accumulated
materials.
Due to hoarding, there may be a lack of
repair/maintenance of property leading
to other health effects on occupier such
as lack of heating (excess cold) or
washing/sanitary facilities.
Usually used in private rented dwellings.
Powers usually used for accumulations
of rubbish or items attracting/ harbouring
rodents on private land. This is usually
used for external parts of property e.g.
gardens.
Information that someone was inside the
premises was ill or injured and the
Police would need to gain entry to save
life and limb
If a premises involves such risk to
persons so serious that the use of the
premises ought to be Prohibited or
Restricted notice can be
served on the responsible person
(owner/occupier).
Cases of Animal mistreatment/ neglect.
The Act makes it not only against the
law to be cruel to an animal, but that a
person must ensure that the welfare
needs of the animals are met.
Health/DEFRA
Local Authority/ Adult
Social Care
National Assistance Act 1948
(Section 47 Power of Removal)
This is the power to remove but not necessarily to resolve so would have to
be used in conjunction with other measures. An assessment would have to
be carried out regarding the person’s living conditions and their best
interest. This would always have to be undertaken by a professional.
Mental Health
Mental Health Act 1983
Section 135(1)
Provides for a police officer to enter a private premises, if need be by force,
to search for and, if though fit, remove a person to a place of safety if certain
grounds are met.
The police officer must be accompanied by an Approved Mental Health
Professional (AMHP) and a doctor.
In general practice an AMHP would apply for the 135(1) warrant at the
appropriate Magistrates Court.
Section 135(1) permits removal to a place of safety for up to 72 hours with a
view to the making of an application under the provisions of the Mental
Health Act or other arrangements for the persons care or treatment.
Mental Health
NB. Place of Safety is usually the mental health unit, but can be the
Emergency Department of a general hospital, or anywhere willing to act as
such.
Section 4 of the Mental Health Act 1983. Admission for assessment in cases
of emergency.
In any case of ‘urgent necessity’.
See also:
http://www.defra.gov.uk/wildlife‐pets/.
Where a person by way of chronic
disease, age infirmity or physical
incapacity is living in insanitary
conditions and is unable to care for
themselves. However, this action may
be open to challenge under the Human
Rights Act 1998 and should only ever be
used as an absolute last resort, with
justification such as reasonable belief it
is to prevent death.
Evidence must be laid before a
magistrate by an AMHP that there is
reasonable cause to believe that a
person
 Is suffering from mental disorder,
and is being
 Ill treated, or
 Neglected, or
 Being kept other than under proper
control, or
 If living alone is unable to care for
self
And that the action is a proportionate
response to the risks involved
In any case of ‘urgent necessity’ an
application may be made by an AMHP
or Nearest Relative and founded on one
medical recommendation made by, if
practicable, a doctor with previous
The criteria for detention mirror Section 2 (below) but Section 4 may be used
in cases of emergency where it has not been possible to secure an
assessment by a second doctor.
Mental health
This section expires after 72 hours unless a second medical
recommendation is received within this time period.
Section 2 of the Mental Health Act 1983.
Admission to hospital for assessment. Application can be made by an
AMHP or Nearest Relative based on 2 medical recommendations in the
prescribed form by 2 independent doctors.
Mental Health
knowledge of the person or a Section 12
approved doctor.
The following grounds must be met:
The person may be detained for a period of up to 28 days.
The person is suffering from a mental
disorder of a nature or degree which
warrants the detention of that person in
hospital for assessment (or assessment
followed by treatment).
Section 3 of the Mental Health Act 1983
That the person ought to be detained in
the interests of his/her own health or
safety or with the view to the protection
of others.
The following grounds must be met:
Admission to hospital for treatment. Application can be made by an AMHP
or Nearest Relative and is based on 2 medical recommendations in the
prescribed form by 2 independent doctors.
The person may be detained initially for a period of up to 6 months for the
purposes of treatment.
That the person is suffering from a
mental disorder of a nature or degree
which makes it appropriate for him/her
to receive medical treatment in a
hospital.
That it is necessary for the health or
safety of the person or for the protection
of others that he/she should receive this
treatment and it cannot be provided
unless the person is detained under this
section. That appropriate treatment is
available for him/her.
APPENDIX 5
Useful Resources
Pan London Hoarding Task Force.
Task force members are representatives from housing associations, other registered providers,
representatives from several local authorities, London Fire Brigade, health and other sectorrelated practitioners.
The task force promotes best practice, develops opportunities to network and work
collaboratively, shares experiences and resources, benchmarks services and helps everyone
work in a more co-ordinated way within London.
For more info go to http://www.peabody.org.uk/news/pan-london-hoarding-taskforce-islaunched.aspx