Mental HealtH Service interventionS for rougH SleeperStoolS and guidance Hosted by Pathway, in

partnership with Lambeth Council, South London and Maudsley NHS Trust, ThamesReach, the Greater London Authority and EASL

2nd edition

I am a consultant psychiatrist and have worked for 25 years with homeless people with serious mental health problems.

For some people who sleep out, a major mental illness has both been the cause of homelessness and also the thing that is keeping the person homeless. It is even mentioned in the ICD, one of the two major systems for classifying diseases and disorders. This observes of some forms of schizophrenia that “with increasing social impoverishment, vagrancy may ensue”.

Some such people do not report clear symptoms or show clear signs of mental illness. However, the people who know them best can see that there is a real problem. The individual will often neglect their self care, sometimes to appalling extremes. They can’t bear the presence of other people, keep themselves very much to themselves and may react angrily when approached. They may say little (or nothing) and show no obvious emotional expression. How can we make sense of this picture?

The problem is that psychiatric diagnosis is usually based on what someone tells me as a psychiatrist. It is much more difficult when I meet someone whose behaviour and history are typical of a psychotic disorder, yet who will not tell me how they are thinking or feeling.

That is why a central feature of this guidance is the use of the Mental Capacity Act to assess the mental state of someone making decisions involving sleeping on the street. Although a conventional “diagnostic interview” may offer no compelling evidence of mental disorder, a mental capacity assessment can clearly demonstrate the result or consequences of such a disorder i.e. the inability to make a particular decision.

My hope is that these tools and guidance will help those working with street homeless people – and those working in mental health services – to better assess and help those who are doubly socially excluded both by homelessness and by serious mental illness.

Foreword by Dr Philip Timms, Consultant Psychiatrist

Contents

Pathway mental health service and implementation team

Introduction

Overview

Risk assessment

Mental Capacity Act guidance

Mental Capacity Act screening tool

Mental Health Act guidance

Mental Health Act screening tool

Hospital admission plan

Guidance on making a safeguarding adults alert

Key words and phrases

Bibliography

Acknowledgements

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4/5 Pathway mental health service and implementation team

Alex Bax Homeless health advisor; Pathway CEO

Paul Davis GLA Rough Sleeping Committee representative; LB Lambeth lead commissioner

Elizabeth Clowes Chair; LB Lambeth

Dr Phil Timms MH Advisor; Consultant Psychiatrist, SLAM

Stan Burridge User engagement advisor; Pathway

Nigel Hewett Medical advisor; Pathway Medical Director

Caitriona Carney Policy advisor; Homeless Link

John O’Neil Training advisor; SLAM

Will Norman Third Sector advisor; Providence Row

Barney Wells Training and advice line provider; Director, EASL

Introduction

These screening tools and guidance were initially developed by a project team comprising of statutory and voluntary sector representatives, and was funded by the GLA and London Borough of Lambeth. The first edition – authored by Jane Williamson & Paul Emerson from SLAM – now requires updating with new requirements such as the Care Act 2014, as well as learning from the application of the screening tools.

The project was set up after a Serious Case Review, published in September 2012, undertaken by the Lambeth Safeguarding Adult Partnership Board. The review concerned a mentally ill person who was sleeping rough and died on the street in the winter of 2010. He had previously been under the care of mental health services and had contact with street outreach teams, ambulance crews and police at his rough sleeping site. He refused all the help that was offered and subsequently died on the street. The Serious Case Review panel decided that it would be helpful to develop a common set of protocols and tools for services working directly with people sleeping rough on the streets.

It is clear that not all homeless people who sleep out are suffering from a mental illness. However across London there is a small but significant group of people who have been sleeping rough for many years and are refusing to accept help to move from the streets. A key theme in the exclusion of such homeless people from mental health services has been an idea that sleeping rough is a lifestyle choice. The experience of the START Team, a community mental health team with over 20 years of working with people sleeping rough, is very different.

Initial engagement with people sleeping rough should be informal and collaborative, and where possible focussed on the needs identified by the person. This guidance is intended for use when all other forms of engagement have failed, been rejected or the situation is very urgent due to significant risk. The aim is to help workers assess mentally ill people sleeping rough and elicit appropriate responses from statutory agencies.

The tools and guidance may also be of use when trying to support hostel residents and other vulnerable adults in any setting who are at risk, not engaging constructively and there is evidence of possible impairment of, or disturbance in the functioning of the mind or brain.

This document therefore includes:• Guidanceonassessingtherisksassociatedwith rough sleeping• GuidanceontheuseoftheMentalCapacityAct– is this individual really making an informed decision to sleep on the streets? • GuidanceontheuseoftheMentalHealthActand developing a hospital admission plan• Guidanceonraisingsafeguardingadultsalerts

The tools and guidance can be found on the Pathway, ThamesReach and Homeless Link websites here:

http://www.pathway.org.uk/services/services/mental-health-guidance-advice/

http://www.thamesreach.org.uk/publications/research-reports/mental-health-service-interventions-for-rough-sleepers-toolkit/?locale=en

There is also a helpline contact available at mentalhealthenquiries @pathway.org.uk; tel: 020 3291 4184 (answering service) provided by EASL (Enabling Assessment Service London) Enquiries will be responded to within 5 working days.

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Overview: where this document can help8/9

Person sleeping rough is refusing offers of help e.g. accommodation,

health care, practical support.

Risk assessmentAssists practitioners in assessing some of the

particular risks associated with rough sleeping.

Mental Capacity Act screening tool

Enables a formal assessment of a person’s capacity to make decisions and in

particular their decision to stay on the street.

Mental Health Act screening tool

Enables outreach workers to assess whether a referral

for a Mental Health Act assessment is appropriate.

Hospital admission planAims to help ensure that the hospital admission

provides effective assessment, interventions

and discharge plans for the person

sleeping rough.

Safeguarding adults guidance

Assists practitioners to raise safeguarding alerts

in respect of people sleeping rough.

riSk aSSeSSMentThis guidance is designed to assist practitioners in assessing some of the particular risks associated with sleeping rough.

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Current mental health

is the person:

•activelyisolatingthemselves?

•lookinganxiousorscared

•confusedand/ordisorientated?

•talkingaloudtothemselvesor otherswhoarenotthere?

•withdrawn,slowinresponseor uncommunicative?

•angry,threateningandaggressive?

•refusingtoattendtotheirmental healthneeds?

•havingdifficultyaccessingmental healthcare?

Current or expected weather conditions

does the person:

•haveappropriateclothingforthe weatherconditions?

•havewarmbedding?

•usedaycentresorotherfacilitiesto shelterfromtheweather?

Isthesleepsiteshelteredanddry?

Level of isolation

is the person:

•isolatingthemselvesfromothers?

•receivingsupportfromother peoplesleepingroughorfamily andfriends?

•avoidingservicesandsupport providedbyhomelessnessservices?

•likelytodevelopatrustingrelationship thatmayleadtothemaccepting accommodation?

Isthesleepsitesafe?

Monitoring arrangements

•Isitpossibletomonitorthe personeffectively?

•Isitpossibletoimplementaplan toreducerisk?

•Isjointworkingneededwithother agenciessuchasdaycentresand streetoutreachteams?

Access to welfare benefits or other statutory support

is the person:

•entitledtosupportfromstatutory services?

(ConsiderdutiestowardsthemunderHousingLegislation https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/7841/152056.pdf orifthey“NoRecoursetoPublicFunds”otherlegislationhttp://www.nrpfnetwork.org.uk/guidance/Pages/default.aspx )

•abletoorganisethemselvesto claimbenefits?

•experiencingparanoidideas thatpreventthemengagingin officialprocesses?

Pattern of homelessness

•Howlonghasthepersonbeen sleepingrough?

•Aretheyconstantlymovingfrom placetoplace?

Thesefactorsmayprovide aframeworktoreferthe personsleepingroughonto appropriateservices.

AdaptedfromLipscombe,S(1997)

Bemindfulofanypotentialrisksassociatedwiththesleepsite.Trytoarrangeameetingpointfortheassessingteamthatiswell litandnottooisolatedastheassessmentmayneedtotakeplaceearlyinthemorningorlateintheevening.

•Isthesleepsitesafe?

•Arethereotherswiththeperson sleepingroughwhomayposearisk?

•Aremembersofthepubliclikelyto getinvolved?

•Doesthepersonhaveahistoryofviolence?

•Doesthepersonhaveadog?

•Doesthepersonhaveaweapon?

The ABC model of riskWhencontactingthepoliceitmaybeusefultocollateriskinformationundertheheadingsbelowusingthismodel.Itisbeingadoptedby theMetropolitanPoliceasawayofassessingriskstovulnerablepeople.Itidentifiesfive keyareastobeassessed

•Appearance and atmosphere:What theassessorfirstseesinapersonin distress,includingphysicalproblems suchasbleeding.

•Behaviour:Whatthepersonindistressis doing,andwhetherthisisinkeepingwith thesituationandtheirusualself.

•Communication:Whatthepersonindistress issayingandhowtheyaresayingit.

•Danger:Isthepersonindistressin dangerandaretheiractionsputting otherpeopleindanger?

•Environment:Whereisthepersonindistress situated,andisanyoneelsethere?

McGlenI,WrightK,CrollD(2008)

Particular risks to consider when carrying out a Mental Health Act assessment (or a mental capacity assessment/ best interests decision)

These pointers should be used to identify some of the particular risks associated with sleeping rough. They should be used to supplement and not replace agencies’ own risk assessment tools.

Key pointers for all practitioners for good practice in assessing risk

12/13riSk aSSeSSMent

Demographic factors

•Istheperson’sage,gender, sexualorientationetc.likelyto leadtoanincreaseinconcern abouttheirvulnerability?

Current physical health

is the person:

•inpoorphysicalhealth?

•refusingtoattendtotheirphysical healthneeds?

•havingdifficultyaccessing physicalhealthcare?

•usingdrugsoralcohol?

•maintainingadequatepersonal hygiene?

•accessingadequatefoodanddrink?

Arephysicalhealthproblemsbeingexacerbatedbysleepingrough?

Key factors for all practitioners (outreach workers, approved mental health professionals, doctors, police, ambulance staff) to consider when assessing risks associated with sleeping rough.

tHe Mental CAPACITyACT2005This includes key pointers for good practice for all practitioners using the Mental Capacity Act to assess a person’s capacity to make a decision.

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•Beclearwhythedecision needs to be made at that point in time e.g. risk to self because of:

•indicationofaseveremental healthproblem(s)

•indicationofaseverephysical healthproblem(s)

•intoxication

•severeweather

•severeselfneglect

•possiblethreatfromothers (butthismayalsorequireapolice/ safeguardingresponse)

•Isthereevidencethattheperson maylackmentalcapacitytomake thedecisionbecauseofaknown/ suspectedmentalhealthproblem, learningdisability,braininjury, dementia,orintoxication,evenafter asmuchhelpaspossiblehasbeen giventothemtounderstandthe decision?Ifso,anassessmentof capacityshouldbecarriedout.

•Ifthereisanindicationofamental disorderandthepersonisposinga risktothemselvesorothersthen anassessmentundertheMental HealthActshouldbeconsidered.

•Theircapacitytomakethedecision shouldalsonotbejudgedsolely onthebasisoftheirappearance, behaviour,ageorcondition.Make suretheyarefreefromexternal pressureswhenmakingthedecision andifpossible,consultwithothers whoknowthepersonwhencarrying outtheassessment.

•Ifthereisevidencethattheperson hasan“impairmentof,ordisturbance inthefunctioningofthemindor brain”(asindicatedbyaknownor suspectedmentalhealthproblem, learningdisability,braininjury, dementia,orintoxication)thenthis mayindicatealackofcapacityand theMCAfourstageassessmentof capacityshouldbecarriedout(more informationabouthisisintheMCA CodeofPractice).Thisinvolves findingoutifthepersoncan:

•understandtheinformation involvedinmakingthedecision;

•retaintheinformationlong enoughtomakethedecision;

•useorweighuptheinformation tomakethedecision;

•communicatetheirdecision.

•Startoffbyassumingtheperson hascapacitytomakethedecision (first principle of the MCA)–butif youareunsurethenanassessment ofcapacityshouldbecarriedout (seebelow).

•Makesurethatasmuchhelp aspossibleisgiventotheperson tounderstandandmakethe decisionthemselves(second principle of the MCA)–butifyou arestillunsureiftheycanmake thedecisionthenanassessment ofcapacityshouldbecarriedout (seebelow).

•Iftheperson’sdecisionappears unwise,eccentricoroddthisis notnecessarilyprooftheylack capacity(third principle of the MCA)butifyouareunsurethen anassessmentofcapacityshould becarriedout(seebelow).

Key pointers for good practice in use of the Mental Capacity Act 2005 (MCA)

16/17tHe Mental capacity ACT2005

•Be clear what the decision is about e.g. consent to:

•assessmentfortreatment orcare

•provisionoftreatmentorcare

•beingconveyedtohospital oracarehome

•goingtoahostelorother accommodation

Key factors for all practitioners (outreach workers, approved mental health professionals, ambulance staff, doctors, police) to consider

Key factors for practitioners carrying out an assessment of capacity and best interests decision under the MCA

Key pointers for good practice in use of the Mental Capacity Act 2005 (MCA)

18/19tHe Mental capacity ACT2005

•Ifonthe‘balance of probabilities’ thepersonisabletodoallfourof theabovethentheyhavecapacity tomakethedecision–evenifthisis anunwiseone.

•Ifonthe‘balance of probabilities’ thepersonisunabletodooneor moreofthefourstagesabovethen theylackcapacitytomakethe decisionanda‘best interests’ decisionneedstobemade(fourth principle of the MCA)onbehalfof thepersonregardingthedecision inquestion(e.g.doestheperson needtreatment,conveyingto hospital,etc.?).

•Thebestinterests‘checklist’ containedintheMCAandtheMCA Code of Practiceshouldalwaysbe followed.Thisincludes:

• involvingthepersonasmuchas possibleinthedecision;

• consideringwhethertheperson mighthavecapacitytomakethe decisionatsomepointandwhat theirdecisionwouldbe;

• theperson’sknownwishesand feelings,beliefsandvaluesthat relatetothedecision;

• notmakingabestinterests decisionbasedsolelyonthe person’sage,appearance, behaviourorcondition;

• ifpossibleandappropriate, gettingtheviewsofothers whohavebeennamedbythe persontoconsultwith,orwho areprovidingcareorsupport totheperson;

• ifthereisno-onetoconsultwith otherthanpaidstaffandthe decisioninvolvesgoinginto hospital,acarehome,orserious medicaltreatmentthenan independent mental capacity advocate(IMCA)shouldbe involved.

•Abestinterestsdecisionshould bemadeonthe‘balance of probabilities’.Itshouldalwaystake intoaccountalternativesthatare ‘less restrictive of the person’s rights and freedoms’ (fifth principle of the MCA),providingitisstillinthe person’sbestinterests.

•Ifabestinterestsdecisionismade involving“acts in connection with care or treatment”thesecanbe carriedoutundertheauthorityofthe MCA.Ifnecessary,theMCAallows youtouserestrainttocarrythisout, buttherestraintmustbeproportionate tothelikelihoodoftheperson sufferingharmandtheseriousnessof thatharmifthecareortreatmentis notprovided.Forexample,ifsomeone hassevere,life-threatening hypothermiaandlackscapacityto consenttogoingintohospitalbut isphysicallyresistingbeingtakenin anambulancethenphysicalrestraint couldbeused.However,iftheir physicalhealthproblemswere non-lifethreateningandtheywere resisting,usingphysicalrestraintto takethemtohospitalwouldnotbe permissible,evenifhospitalhadbeen deemedtobeintheirbestinterests.

•Whendoingamentalcapacity assessmentorbestinterestsdecision itmaybeusefultoconsiderthe riskfactorsintheriskguidance forcarryingoutaMentalHealth Actassessment.

•Makesureyourecord:

• theassessmentofcapacity;

• theoutcomeoftheassessment;

• thebestinterestsdecision;

• anyactionsinconnectionwith theperson’scareortreatment thatwerebasedonthebest interestsdecision,includingany useofrestraint.

Other helpful resources

•TheMCAScreeningToolis designedtohelpguideyouthrough thisprocess.

•TheMCACodeofPracticegives importantguidanceonhowtofollow theprinciplesoftheMCA,carry outanassessmentofcapacityand bestinterestsdecision,andprovide careandtreatmenttopeoplewho lackcapacity.Ifyouaredoing anassessmentofcapacityor bestinterestsdecisionyoushould refertothis.

tHe Mental capacity act Screening toolThis tool is designed to enable a formal assessment of a person’s capacity to make decisions, and in particular their decision to stay on the street.

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Mental Capacity Act (MCA) screening tool for street outreach teams

22/23tHe Mental capacity act Screening tool

3Hassufficientinformationbeengiventothepersontohelpthemunderstandthedecision?

Yes NoName of person:

DOB:

Rough sleeping location:

Date of assessment:

1Whatisthedecisionthepersonyouareconcerned aboutneedstomake,andwhy dotheyneedtomakethisdecisionnow?

2Istherereasontobelievethatthepersonmaylackmentalcapacitytomakethedecisionduetoaknown/suspectedmentalhealthproblem,learningdisability,braininjury,dementia orintoxication?

Yes No

4Haveallpracticablestepsbeentakentosupportthepersontomakethedecision?

Yes No

5Isitfeltthatthepersonisfreefromexternalpressurestomaketheirdecision?

Yes No

Mental Capacity Act (MCA) screening tool for street outreach teams

24/25tHe Mental capacity act Screening tool

6Canthepersonunderstandinsimplelanguagetheinformationinvolvedinmakingthedecision?

Yes No

9Cantheycommunicatetheirdecision(whetherbytalking,usingsignlanguageoranyothermeans)?

Yes No

11Howdidyoudecidewhatwasintheperson’sbestinterests?

12Whatactionshouldbetakenintheperson’sbestinterests?

7Cantheyretaintheinformationlongenoughtomakethedecision?

Yes No

8Cantheyuseorweighuptheinformationtomakethedecision?

Yes No

Ifthepersonisunabletodemonstratetheirabilityinoneormoreofthefourareasbelow,thentheylackcapacitytomakethedecisionanditneedstobemadeintheirbestinterests.

Name of person completing form: Date:

10Thedecision: doesthepersononthebalanceofprobabilitieshavethecapacitytomakethespecificdecisionatthisparticulartime?

Yes No

Assessment of capacity

6 Can the person understand in simple language the

information involved in making the decision?

Ensurethattheoptionshavebeenexplainedclearlyanduseinterpreters orotherformsofcommunication asrequired.

9 Can they communicate their decision (whether

by talking, using sign language or any other means)?

Ifapersonissleepingroughand notspeakingdespitebeingat significantriskyoumaydecidethat theylackcapacity.

Failuretocommunicatemayalsobe duetoinebriationorunconsciousness.

10The decision: does the person on the balance of

probabilities have the capacity to make the specific decision at this particular time?

Indicatehereunderwhichofthefourcriteriatheserviceuserdemonstratesthattheylackcapacity.Thereisno needtorepeatthedetailsofwhythis isthecase.

11 How did you decide what was in the person’s

best interests?

Indicateherehowyoufollowedthebestinterests‘checklist’.

12 What action should be taken in the person’s

best interests?

Thisspaceallowssuggestionstobemadeastowhatthatactionmightbe.

Itmaybeadvisabletoconsidertheoptionsof‘takingaction’or‘nottakingaction’,lookingattheadvantagesanddisadvantagesofeach.

Anyactiontakenshouldbetheleastrestrictiveoftheperson’srightsandfreedominlinewiththefifthprincipleoftheMCA,providingitisstillintheperson’sbestinterests.

7 Can they retain the information long enough

to make the decision?

Thepersonmustbeabletoholdtheinformationintheirmindlongenoughtomakeaneffectivedecision.Theyonlyneedtoshowthattheyareabletoretaintheinformationspecifictothatdecision.

8 Can they use or weigh up the information to make

the decision?

Isitfeltthatthepersonisabletounderstandtheprinciplerisksandbenefitsofwhatisproposed?

Thepersonmayunderstandtheinformation,butanimpairmentordisturbancestopsthemusingorweighingthisup.Forexampleapersonsleepingroughmaybeabletodemonstratethattheyunderstandtheconsequencesofrefusingaccommodationbutparanoiaordelusionalbeliefspreventthem fromusingthisknowledgeto maketheirdecision.

Thepersonmayagreethatrefusinghealthcareputsthematseriousrisk butstilldeclinehelp.Thiscouldbe seenasdemonstratinganinability touseandweightheinformation.

Guidance regarding the Mental Capacity Act screening tool

26/27tHe Mental capacity act Screening tool

Please outline reasons under each section. Do not simply answer yes/no

1 What is the decision the person you are concerned

about needs to make, and why do they need to make this decision now?

Examplesmayincludeadecisionto gotohospitalregardingphysical healthproblemsortoacceptanoffer ofaccommodation.

Canthedecisionmakingprocess bedelayed?

3 Has sufficient information been given to the person

to help them understand the decision?

Thisshouldincludethenatureofthedecision,thereasonwhyitisneededandthelikelyeffectofdecidingonewayoranotherormakingnodecisionatall.

Ifthedecisionisaboutmovingto hostelaccommodationyoushouldproviderelevantdetailswhichmayincludephotos,writteninformationor aninformalvisit.

4 Have all practicable steps been taken to support the

person to make the decision?

Apersonshouldnotbetreatedasunabletomakeadecisionunlessallpracticablestepstohelphimtodosohavebeentakenwithoutsuccess.

Recorddetailsofdiscussionswith thepersonaboutthedecision.

2 Is there reason to believe that the person may lack

mental capacity due to a known/suspected mental health problem, learning disability, brain injury, dementia or intoxication?

Thepersonmustbeassumedtohavecapacityunlessprovedotherwise.Ifyouanswered‘no’thentheyareassumedtohavecapacityandnofurtherassessmentisrequired.

Ifyouanswered‘yes’thentheassessmentmovestothenextstage.

youwillneedtooutlineanybehaviourthatleadsyoutosuspectthatthisis thecase,althoughacleardiagnosis isnotrequired.

5 Is it felt that the person is free from external pressures

to make their decision?

Forexample,aretheybeingpressurisedbyfriendsoracquaintances?

tHe Mental HealtH ACT1983This includes key pointers for good practice for all practitioners in use of the Mental Health Act.

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Key pointers for good practice in use of the Mental Health Act 1983

30/31tHe Mental HealtH ACT1983

Be clear about any signs of mental disorder that you are aware of:

•youarenotexpectedtomakea diagnosisorusejargon,simply describetheappearanceor behaviouroftheperson.

•Describeif/howtheperson’shealth hasdeteriorated.

•Aretheproblemssevereoracute?

•Areyouawareofanyprevious psychiatrichistoryordiagnosis?

Be clear about any concerns that you have about the person’s health or safety or the risk that they present to others

InordertomeetthecriteriafordetentionundertheMentalHealthAct(MHA)thepersonneedstopresentarisktoeithertheirownhealthORtheirownsafetyORtothesafetyofothers.AriskinanyoneofthesecategoriesissufficienttoconsiderassessmentundertheMHA.

Concernsabouthealthcouldinclude:

•Physicalhealth

•Mentalhealth

Concernsaboutsafetycouldinclude:

•Selfneglect

•Selfharm

•Suicide

•Environment

•Threatfromothers

•Threattoothers

•Thelattertwomayalsorequirea policeorsafeguardingresponse.

Be clear about what other support or interventions have already been offered

•Accommodation

•Practicalsupport-food, clothing,finances

•Daycare

•Medicationortreatment

•Informalhospitaladmission

Other helpful resources:

the MHA Code of Practicegivesimportantguidanceonhowtofollow theprinciplesoftheMHA.

the MHA screening toolisdesigned tohelpguideyouthroughthisprocess.

Be clear about any other people involved

•Daycentrestaff

•Outreachworkers

•Friends

•Carers

•Relatives

Key factors for all practitioners to consider when working with a person sleeping rough who may have a mental disorder.

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tHe Mental HealtH act Screening toolThis tool enables outreach workers to assess whether a referral for a Mental Health Act assessment is appropriate.

Mental Health Act 1983 screening tool

34/35tHe Mental HealtH act Screening tool

Name of person:

DOB:

Rough sleeping location:

1is the person showingsignsofmentaldisordertotheextentthattheyneedadmissiontohospitalforassessmentandortreatment?

Yes No 3Whatothersupportorinterventions havealready beenoffered?

2is the person presentingarisktotheirownhealthorsafetyor to other people?

Yes No 4Arethereanyrelatives,carersorotherservicesinvolved?

Yes No

Name of person completing form: Date:

Guidance regarding the Mental Health Act 1983 screening tool

36/37tHe Mental HealtH act Screening tool

1 Is the person showing signs of mental disorder to the

extent that they need admission to hospital for assessment and or treatment?

•Formanypeoplesleepingrough youmaynotbeabletoprovidedetails abouttheperson’spsychiatrichistory ordiagnosisasthisinformationmay beunknownorunclear.

•Describehowthementaldisorderis beingexhibitede.g.activelyisolating themselves,talkingaloudtoothers whoarenotthere.

•Drugoralcoholdependencealoneis notconsideredtobeamentaldisorder undertheMentalHealthAct(MHA). Howeveritmaybeaccompaniedby amentaldisorderwhichdoesfall withintheAct.

•Ifpossiblestatewhyyoubelieve thattheperson’srefusaltoaccept accommodationorsupportis linkedtoamentaldisorderin ordertochallengetheassumption thatthepersonismakinga lifestylechoice.

2 Is the person presenting a risk to their own health or

safety or to other people?

•Healthandsafetyrisksmayalso includetheperson’slevelofself neglectcomparedwithotherpeople sleepingrough,e.g.lackofshelter atsleepsite,verypoorselfcareand nutritionalintake,refusaltoattend daycentresoracceptoffersof clothing,foodanddrink.

•Untreatedmentalillness,especially whereitisleadingtoaperson becominghomelessmayconstitute arisktohealth.

3 What other support or interventions have already

been offered?

Theapprovedmentalhealthprofessional(AMHP)shouldconsidertheleastrestrictivealternativesoitisimportanttoprovidedetailsofthefollowing

•Arethereanyalternativesto detentioninhospital?

•Canthepersonreceivethe assessmentortreatmentinany otherway?

•Aretheywillingtogotohospital voluntarily?

•Arethereanyotherwaysthatrisk canbereduced?

•Isthereanyaccommodationavailable fortheperson?

4 Are there any relatives, carers or other services

involved?

TheAMHPshouldcontactother relevantpeopleandforsomesectionsoftheMHAwillneedtoconsultwith theperson’snearestrelative.Manypeoplesleepingroughhavelost contactwithrelatives;howeveritwill behelpfultoprovideanydetailsthat youhave.

•youshouldensurethatanydecisions takenmaximisethesafetyandmental andphysicalwellbeingoftheperson beingassessed.

•youshouldworktopromotethe person’srecovery.

•youshouldprotectotherpeople fromharm.

•youshouldattempttousetheleast restrictiveoption.

•youshouldrecogniseandrespectthe diversityofthepersonbeingassessed andtakefactorssuchasethnicity, age,genderintoaccount.

•youshouldconsidertheviews, wishesandfeelingsoftheperson.

•youshouldgivethepersonthe opportunitytoplan,deliverand reviewtheirowntreatmentasfar aspossibletoensurethatitis appropriateandeffective.

•youshouldencourageinvolvement ofcarersorotherinterestedpeople.

(MHA Principles - MHA Code of Practice)

Principles for AMHPs and doctors carrying out a MHA assessment

Please outline reasons under each section. Do not simply answer yes/no

Guidance regarding the Mental Health Act 1983

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Relevant sections of the MHA

•Peoplesleepingroughwillusuallybe assessedunderSection2MHA.

•Section3maybemoreappropriate forpeoplewhoarewellknown toservices,wherethereisaclear diagnosisandtreatmentplan.

•Section4foremergencyassessment, orpolicepowersunderSection 136mayneedtobeconsideredin urgentsituations.

•Section135warrantsforpoliceto searchforandremovepersonsare notusuallyneeded.(seebelow)

•Section7and8useofGuardianship maybeconsideredtorequireaperson toliveinaspecifiedplace.

Doctors

Involveadoctorwhoknowsthepersonorwhohasknowledgeandexpertiseinassessingpeoplesleepingrough,whereverpossible.

Location of the assessment

ThelawdoesnotpreventaMentalHealthActassessmenttakingplaceonthestreet;howeveritcanbedifficulttointerviewthepersoninapublicplace.Ifthepersonattendsalocaldaycentreitmaybepreferabletoarrangetheassessmentthere.

Iftheassessmenthastotakeplaceonthestreetitisimportanttogatherinformationabouttheperson’spatternsofactivityandsleepsitepriortotheassessment.Streetoutreachteams,communitywardens,policesaferneighbourhoodteams,andparkdepartmentstaffareoftengood sourcesofinformation.

youwillneedtocheckthefollowing:

•Whattimesdoesthepersonsleeping roughbeddownorgetupinthe morning?

•Whereelsecanthepersonsleeping roughbeseenotherthantheir sleepsite?

•Iftheassessmentneedstotakeplace atthesleepsiteatwhattimemightit beleastbusytominimisedisruption andmaximiseconfidentiality?(E.g. avoidingrushhourorlunchtimes)

•Isthereaplacenearbywhichismore private?(E.g.aquietersidestreet orpark).

•Isthesleepsiteonprivatelandandifso isaSection135(1)warrantrequired?

•Doesthepersonattendadaycentre?

•Whattimesanddaysoftheweek dotheyattend?

•Dodaycentrestaffagreethatthe assessmentcantakeplaceonthe premises?

Warrants

•ASection135warrantisnotnecessary iftheassessmentistakingplaceonthe street.HoweveranAMHPmayneed toconsiderapplyingforawarrantif theassessmentistakingplaceinthe publicareaofadaycentre.

•Otherlocationswhichmayrequire awarrantareabandonedcars andbuildings.

Personal safety – see Risk Section

•Hasconsiderationbeengiventoa suitablerendezvouspoint?

Trytoarrangeameetingpointfortheassessingteamthatiswelllitandnottooisolatedastheassessmentmayneedtobesetupearlyinthemorning orlaterintheevening.

Police powers under Section 136 of the Mental Health Act 1983

PoliceareoftencalledouttoattendtopeoplesleepingroughandhavepowersunderSection136totakeapersontoaplaceofsafetyforassessment.Policeofficerswillneedtobesatisfiedthatthepersonappearstosufferfromamentaldisorderandthattheyareinimmediateneedofcareorcontrol.Ifyouneedtocallthepoliceitisuseful tousetheABCmodelreferredtounder theRiskSection.PolicewillusuallyexpectmentalhealthservicestointerveneifthesituationisnoturgentratherthanuseSection136.HoweverifthereisanurgentsituationthatrequiresimmediateactionuseofSection136maybeappropriate.Variousfactorssuchassevereweathermayinfluence thisdecision.Itmaybeusefulfortheoutreachworkertoattendthe136suitewiththepolicetoassistwithprovidinginformationforanysubsequentassessment,andhelpwithalternativestoadmissioniftheoutcome isnottoadmit.IfthepoliceagreetoconsideruseofSection136theMentalHealthTrustshouldidentifytheplaceofsafety.IfthepersonsleepingroughisdetainedunderS136conveyancetotheplaceofsafetyshouldbebyambulanceunlessthereisgoodreasontoconveyinapolicevehicle.Ifthepersonisadmittedtohospitalitisalsousefultoprovideahospitaladmissionplanwhereverpossible.

Alternatives to hospital admission or detention under the MHA

•Istheresuitabletemporary accommodationavailableincluding hostels,nightsheltersorbedand breakfasthotels?

•Doesthelocalmentalhealthcrisis interventionteamworkwithpeople sleepingrough?Aretheywilling toassess?

•Willthepersonsleepingroughattend adaycentreorengagewithother servicestoreducerisk?

•Isthepersonwillingtogoto hospitalvoluntarily?

•CouldGuardianshipbeusedasaless restrictivealternative?

•Haveyouconsidereduseofthe MentalCapacityAct?

Applying to the magistrate for a warrant

BelowaresomepointsyoumaywanttoconsiderwhenprovidingtheinformationtotheMagistrate.

•Haveyoumadereasonableattempts toaccessthesleepsiteandinterview thepersonwithoutawarrant?

•Doesthepersonhaveahistoryof notengagingwithservices?

•Arethererisksassociated withaccessingthesleepsite withoutpolice?

•Isthereariskthattheperson willchangesleepsiteandbelost toservices?

Key factors for AMHPs to consider in setting up a Mental Health Act assessment for a person sleeping rough.

tHe HoSpital adMiSSion planThis plan aims to help ensure that the hospital admission provides effective assessment, interventions and discharge plans for the person sleeping rough.

40/41

Hospital admission plan42/43tHe HoSpital adMiSSion plan

Name of person:

DOB:

Rough sleeping location:

1Reasonswhyhospitaladmission isneeded, (attachMHAScreeningTool)

3Riskstoselfandothers

2Evidenceofmentaldisorder

4Detailsofpreviouspsychiatrichistory (ifknown)

Hospital admission plan44/45tHe HoSpital adMiSSion plan

5Whatothersupportandinterventionshavealreadybeenoffered?

7Whatfactorswillindicatethatthepersonisreadyfordischarge?

6does the personlackcapacity?Ifso,attachtheMCAScreeningTool

8Whatactionsneedtobetakenbywardstaffand/orotherstofacilitateappropriatedischarge?

Name of person completing form: Date:

guidance on raiSing Safeguarding adultS alertSThis guidance aims to assist street outreach workers and other practitioners to raise safeguarding alerts regarding people sleeping rough.

46/47

Key pointers for good practice in raising safeguarding concerns

48/49guidance on raiSing Safeguarding alertS

•ASafeguardingAdultsEnquiryisa multi-agencyresponse,coordinated byalocalauthority,withtheaimof producingasharedunderstandingand shareddecisionmakinginsituations wherepeoplewithcareandsupport needsareatriskofexperiencingharm orabuse.Thismaybeanalternative approachtomanagetherisksfaced byapersonsleepingrough.

•Safeguardingadultssituationsare wherethereisariskof,oractual, abuseorneglectofapersonwith careandsupportneeds.Theabuse mightbebysomeoneelse,whetheran organisationoraninstitution,orbe self-neglect.Safeguardingdoesnot refertosituationswhensomeoneisat riskorbecomingdistressedbecause ofmentalillnessorotherhealth problemsanddisabilities.

•Itisn’trelevantwhethertheabuse orneglectmaybeintentionalor not,orwhetherthepersonhasthe mentalcapacitytomakedecisions aboutmanagingriskandprotecting themselves.

•TheCareAct2014andtheCareand Supportstatutoryguidancecreate alegalframeworkfororganisations andindividualswithresponsibilities forsafeguardingadultstowork togethertopreventabuseand neglectandtorespondtoconcerns whentheyarise.

•Thereisadutyonthelocalauthority tohaveasafeguardingenquirywhere anadult:

• hasneedsforcareandsupport (whetherornotthelocalauthorityis meetinganyofthoseneeds)and;

• isexperiencing,oratriskof,abuse orneglect;and

• asaresultofthosecareand supportneedsisunabletoprotect themselvesfromeithertheriskof, ortheexperienceofabuseor neglect.

Types of abuse

TheCareandSupportstatutoryguidancegivesthefollowingcategories:

Physical abuse–includingassault,hitting,slapping,pushing,misuseofmedication,restraintorinappropriatephysicalsanctions.

Domestic violence–includingpsychological,physical,sexual,financial,emotionalabuse;so called‘honour’basedviolence.

Sexual abuse–includingrape,indecentexposure,sexualharassment,inappropriatelookingortouching,sexualteasingorinnuendo,sexualphotography,subjectiontopornographyorwitnessingsexual acts,indecentexposureandsexualassaultorsexualactstowhichtheadulthasnotconsentedorwaspressuredintoconsenting.

Psychological abuse–includingemotionalabuse,threatsofharm orabandonment,deprivationofcontact,humiliation,blaming,controlling,intimidation,coercion,harassment,verbalabuse,cyberbullying,isolationorunreasonable andunjustifiedwithdrawalofservicesorsupportivenetworks.

Key factors for all practitioners (outreach workers, approved mental health professionals, ambulance staff, police) to consider

Financial or material abuse – includingtheft,fraud,internetscamming,coercioninrelationtoanadult’sfinancialaffairsorarrangements,includinginconnectionwithwills,property,inheritanceorfinancialtransactions,orthemisuseormisappropriationofproperty,possessionsorbenefits.

Modern slavery–encompassesslavery,humantrafficking,forcedlabouranddomesticservitude.Traffickersandslavemastersusewhatevermeanstheyhaveattheirdisposaltocoerce,deceiveandforceindividualsintoalifeofabuse,servitudeandinhumanetreatment.

Discriminatory abuse–includingformsofharassment,slursorsimilartreatment;becauseofrace,genderandgenderidentity,age,disability,sexualorientationorreligion.

Organisational abuse–includingneglectandpoorcarepracticewithinaninstitutionorspecificcaresettingsuchasahospitalorcarehome,forexample,orinrelationtocareprovidedinone’sownhome.Thismayrangefromoneoffincidentstoon-goingill-treatment.Itcanbethroughneglectorpoorprofessionalpracticeasaresultofthestructure,policies,processesandpracticeswithinanorganisation.

Key pointers for good practice in raising safeguarding alerts

50/51guidance on raiSing Safeguarding alertS

Referring safeguarding adults concerns

Organisationsworkingwithpeoplewhomayhavecareandsupportneedsmustmakethelocalauthorityfortheareawheretheabuseorneglecttookplaceorisatriskofhappeningawareofsituationswhereasafeguardingenquirymaybeneeded.TheCareandSupportstatutoryguidancesaysitisnotforfrontlinestafftosecond-guesstheoutcomeofanenquiryindecidingwhetherornottosharetheirconcerns.Eachorganisationshouldhavepoliciesandprocessesabouthowtheydothis.

Whenreportingasafeguardingadultsconcernsissues,beclearaboutwhatleadsyoutobelieve

•Thepersonhasexperienced,orisat riskof,abuseorneglect

•Thepersonhascareandsupport needs,andhowthispreventsthem fromprotectingthemselves

Ifyouareable,youshouldalsofindoutfromthepersonwhohasexperiencedorisatriskofabusewhattheywanttohappen.TheCareandSupportstatutoryguidancepromotestheMakingSafeguardingPersonalapproach,whichinvolvesallthoseinvolvedfindingoutwhatoutcomesthepersonwants,andworkingtogethertomeetthemasbestasweareable.

What happens next?

Thelocalauthoritywilldecideifthedutytohaveanenquiryhasbeenmet.Ifithas,itwilldecidewhatformtheenquirywilltake.Theobjectivesoftheenquiryare

•toestablishfacts

•toascertaintheadult’sviewsand wishes

•toassesstheneedsoftheadultfor protection,supportandredressand howtheymightbemet;

•toprotectfromtheabuseandneglect, inaccordancewiththewishesof theadult;

•tomakedecisionsastowhatfollow- upactionshouldbetakenwith regardtothepersonororganisation responsiblefortheabuseor neglect;and

•enabletheadulttoachieveresolution andrecovery.

Meetingtheseobjectivesneedinvolveactionsbythelocalauthority,butthelocalauthorityisresponsibleforensuringtheenquirytakesplace.Anenquirymightinvolveseveralstrands,andcouldincludethingslikeanassessmentofneedforcareandsupport,policeenquiry,acomplaintsprocess,oractionsbyanemployerorproviderofservices.Whatmakesitasafeguardingenquiryisthecoordination,andthesharedfocusontheabuseorneglectissue.

Oncetheenquiryiscompleted,thelocalauthoritymustdecideonwhatactions,ifany,areneededandwhoby.Thiscanbeintheformofasafeguardingplan.

Other helpful resources

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/366104/43380_23902777_Care_Act_Book.pdf See in particular section 14, Safeguarding

https://s3-eu-west-1.amazonaws.com/media.dh.gov.uk/network/497/files/2014/05/14_Guidance_safeguarding.pdf

http://www.legislation.gov.uk/ukpga/2014/23/part/1/crossheading/safeguarding-adults-at-risk-of-abuse-or-neglect/enacted

Neglect and acts of omission – includingignoringmedical,emotionalorphysicalcareneeds,failuretoprovideaccesstoappropriatehealth,careandsupportoreducationalservices,thewithholdingofthenecessitiesoflife,suchasmedication,adequatenutritionandheating.

Self-neglect–thiscoversawiderangeofbehaviourneglectingtocareforone’spersonalhygiene,healthorsurroundingsandincludesbehavioursuchashoarding.

•Self-neglectwasarelativelylate additiontosafeguardingcategories andpresentschallengestocommonly heldbeliefsregardinglifestylechoices orfailuretoengage;TheCareAct guidancerecognisestheissuesraised bysafeguardingandself-neglect,and proposesthateachlocalauthority’s SafeguardingAdultsBoardprovides leadershipandguidanceregarding approachestoself-neglect.

Key words and phrases used52/53

ABC assessment tool AtoolbeingimplementedbytheMetropolitanPoliceServicetoassessrisk.

Approved Mental Health Professional (AMHP)Asocialworkerorotherprofessionalapprovedbyalocalauthoritytocarryout avarietyoffunctionsundertheMentalHealthAct.

Decision–maker Apersonrequiredtomakedecisionsoractonbehalfofsomeonewholackscapacitytomakedecisionsforthemselves.Thedecisionmakerhasaresponsibilitytoworkoutwhatwouldbeinsomeone’sbestinterests.

Mental Health Act 1983 (amended 2007) Alawmainlyaboutthecompulsorycareandtreatmentofpeoplewithmentalhealthproblems.• Section 2-Admissionforassessment (orforassessmentfollowedby treatment)• Section 3 -Admissionfortreatment• Section 4 -Admissionforassessment incaseofemergency• Sections 7 and 8–‘Guardianship’ Arrangementsmadetoappointa guardianforapersonwithamental disordertoensurethattheperson getsthecaretheyneedinthe community.• Section 135 (1)-Warranttosearch forandremovepatients.• Section 136-Mentallydisordered personsfoundinpublicplaces.• Mental Health Act assessment – Theprocessofexaminingor interviewingapersontodecide whetheranapplicationfordetention orguardianshipshouldbemade.

Section 12 doctorAdoctorwhohasbeenapprovedbytheSecretaryofStateundertheMentalHeathActashavingexperienceinthediagnosis ortreatmentofmentaldisorder.

Street outreach teams Teamsthatengagewithpeoplesleepingroughonthestreetsduringearlymorningandlate-nightshifts.TheyoftenhaveaccesstohostelorothertemporaryaccommodationandprovidearangeofpracticalsupportincludingwelfarebenefitsadviceandmakingreferralsontoappropriateagenciessuchasmentalhealthteamsandGPs.

Independent Mental Capacity Advocate (IMCA) Someonewhoprovidessupportandrepresentationforapersonwholackscapacitytomakespecificdecisionswhenthepersonhasno-oneelsetosupportthem.

Mental Capacity Act 2005 Alawthatgovernsdecisionmakingonbehalfofpeoplewholackcapacity.

Best interests Anydecisionsmade,oranythingdonefor apersonwholackscapacitytomakespecificdecisionsmustbeintheperson’sbestinterests.

Capacity Theabilitytomakeadecisionaboutaparticularmatteratthetimethedecisionneedstobemade.

Care Act 2014 TheCareAct2014createsalegalframeworksokeyorganisationsandindividualswithresponsibilitiesforadultsafeguardingcanagreeonhowtheymustworktogetherandwhatrolestheymust playtokeepadultsatrisksafe.

Bibliography

Ballintyne,S(1999)UnsafeStreets: TheStreetHomelessasVictimsofCrime,NewEconomy,June1999,(6) (2)pp.94-97.

DepartmentofConstitutionalAffairs(2007)MentalCapacityAct2005 CodeofPractice,London:TSO.

DepartmentofHealth(2000)NoSecrets:guidanceondevelopingandimplementingmulti-agencypolicies andprocedurestoprotectvulnerableadultsfromabuse,London:DOH.

DepartmentofHealth(2008)ReferenceGuidetotheMentalHealthAct1983,London:TSO.

Jones,R(2012)TheMentalHealth ActManual(15thEd.),London:Sweet &Maxwell.

Jones,R(2012)TheMentalCapacity ActManual(5thEd.),London:Sweet &Maxwell.

Lipscombe,S(1997)Homelessness andMentalHealthRiskAssessment, InKemshall,HandPritchard, J(Eds)(1997);GoodPracticein RiskassessmentandRisk Management2Protection,Rights andResponsibilities,London: JessicaKingsley.

McGlen,IWrightK,CrollD(2008) TheABCofMentalHealth,EmergencyNurse.Nov2008,Vol.16Issue7, p25-27.

Reeve,K(2011)Thehiddentruthabouthomelessness:experiencesofsinglehomelessnessinEngland,CrisisUK

SCIE(2011)Protectingadultsatrisk:Londonmulti-agencypolicyandprocedurestosafeguardadults fromabuse,London:SCIE

SCIE(2011)Safeguardingadultsat riskofharm:Alegalguideforpractitioners,London:SCIE

Teixeira,L(2010)Stillleftout?Thepersonsleepingroughs‘205’initiativeoneyearon,London:Crisis.

WHO(1992)TheICD-10ClassificationofMentalandBehaviouralDisorders,Geneva:WHo

54 Acknowledgements

Who offered assistance and advice with the development of the initial project

Jane Barnes Team Manager: National Social Work Team and Substance Misuse Team, South London and Maudsley NHS Foundation Trust

With thanks to:

Mitchell Bateman Mental Health Lead, British Transport Police Service

Simon Cribbens Senior Policy Officer, Housing Policy Strategy and Services, Greater London Authority

Kudakwashe Dimbi Clinical Advisor for Mental Health, London Ambulance Service

Natalie Hammond Consultant Nurse: Promoting Safe and Therapeutic Services, South London and Maudsley NHS Foundation Trust

John O’Neil Team Manager: Homelessness Training Unit, South London and Maudsley NHS Foundation Trust

Nina Houghton Mental Health Lead, City of London Police Service

Rodney Johnston Mental Health and Policing, Metropolitan Police Service

Clive Palmer Social Work Liaison Officer, London Ambulance Service

Alan Taylor Head of Safeguarding Adults, London Ambulance Service

Barney Wells Director: Enabling Assessment Service London

Frankie Westoby Mental Health Lead, Metropolitan Police Service

Toby Williamson Head of Development and Later Life, Mental Health Foundation

The London Street Outreach Teams, with special thanks to: Ealing Outreach (St Mungo’s), Tower Hamlets Outreach (Thames Reach), London Street Rescue (Thames Reach),

Homeless Link, Thames Reach and Pathway for hosting the tools online.

Paul Emerson Project Manager: Rough Sleeper Project, Approved Mental Health Professional, Southwark Council

Jane Williamson Project Supervisor, Clinical Services Lead, South London and Maudsley NHS Foundation Trust

Michelle Binfield Rough Sleeping Advisor, Senior Commissioning and Programme Manager, London Borough Of Lambeth

Original steering group

Elizabeth Clowes Chair, Assistant Director, Social Inclusion, London Borough of Lambeth

Jane Gregory Safeguarding Advisor, Safeguarding Adult Policy and Development Coordinator, London Borough of Lambeth

Will Norman Third Sector Advisor, Lead Manager: Tower Hamlets SORT, Thames Reach

Dr Philip Timms Mental Health Advisor, Consultant Psychiatrist: START Team, South London and Maudsley NHS Foundation Trust

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