2.9. Safeguarding and multiple compound needs

2.9.1. Introduction

Multiple compound needs, or multiple disadvantage/complex needs, is defined locally as people who experience three or more of the following:

• Homelessness
• Current or historical offending
• Substance misuse
• Domestic abuse
• Mental Health difficulties

These various needs interact or exacerbate each other, so that a combination of increasing health and social care needs are experienced simultaneously.

This definition of multiple compound needs is not exhaustive. Professional curiosity should be used in taking a broad approach to the identification of care and support needs, and those who have a combination of needs. People with multiple compound needs may require enhanced support and/or safeguarding interventions in responding to risk.

The Department of Levelling Up, Housing and Communities (DLUHC) highlight that a significant proportion of people with multiple compound needs are neurodivergent; including those with learning disabilities, acquired brain injuries (ABI), alcohol related brain damage, Autism Spectrum Disorder (ASD), and Attention Deficit Hyper Disorder (ADHD). Other factors can include trauma, poverty, poor physical health, and undiagnosed brain injuries.

The inability to manage health and care needs, or to maintain their home environment, is a further frequent occurrence and can lead to self-neglect taking place. In situations where self-neglect is identified it is key the guidance on self-neglect in these procedures are followed (see Section 2.8. Sussex multi-agency procedures to support adults who self-neglect).

This may apply to an estimated 363,000 people in this situation across England. They are among the most vulnerable in our communities, and often experience entrenched disadvantage, trauma, and health inequalities including early mortality while experiencing barriers in accessing the support they require. A number of programmes, such as Changing Futures Sussex, and Safeguarding Adult Reviews (SARs) have highlighted the importance of coordinated and proactive person centred, trauma informed support to improve the lives of those experiencing multiple and compound needs and there is a growing body of evidence to support this.

2.9.2. Language

A number of terms can be used to describe adults experiencing multiple and compound needs; these include multiple and complex needs, multiple needs, severe and multiple disadvantage, deep or chronic social exclusion, and multiple exclusion homelessness.

These terms can be used interchangeably but in Sussex we are moving towards a more consistent approach to language in this area with the term multiple compound needs being used.

2.9.3. Making Safeguarding Personal

The importance of a person-centred approach in supporting and safeguarding is embedded in the Care Act 2014 and the accompanying statutory guidance. This means putting the person at the heart of the process to understand their needs, views, desired outcomes, and wellbeing.

As detailed in section 1.1.3., a person-centred approach means actively involving the person in discussions, and ensuring their views and desired outcomes are recorded and shared with relevant agencies.

If this is not possible, or has not taken place, it is vital that this is recorded in their care plan and/or other records. The views of family, carers, friends, or advocates should be sought and recorded to evidence that a person-centred approach has been adopted.

A person-centred approach in supporting and safeguarding those with multiple compound needs will include consideration of their life experiences, the impact of significant events, and their longer-lasting effects. If the person’s story is not considered this could result in tackling symptoms rather than addressing underlying causes. Their experiences, significant events and effects may include:

Trauma

A high proportion of people experiencing multiple compound needs are also likely to have experienced trauma. This may be adverse childhood experiences (ACE), such as childhood abuse or neglect, living with someone with severe mental illness, or parental loss. Trauma can arise from historic abuse or neglect, bereavement, imprisonment, having been a child in care, loss of family/children, or multiple traumas leading to post-traumatic stress disorder (PTSD).

For further information on trauma-informed and psychologically informed approaches and safeguarding please see Section 1.1.6. on trauma-informed approaches.

For further information on adverse childhood experiences please see Overview of ACEs - Adverse Childhood Experiences (ACEs) - Children - Population groups - Public Health Scotland (opens in a new window).

Professional curiosity

Professional curiosity means a willingness to engage with the person to explore situations or circumstances holistically rather than making assumptions or accepting things at face value. It includes recognising that care and support needs can evolve and a broad interpretation is required in the identification of these. Being open to new and unexpected information and incorporating this assists in recognising, reporting and responding to potential vulnerabilities such as abuse or neglect.

Professionals need to manage uncertainty, consider, and analyse all possible explanations, and be prepared to ‘think the unthinkable’.

Professional curiosity helps to understand the ongoing impact of trauma and adverse experiences for those with multiple compound needs.

Engagement

Previous trauma, undiagnosed physical/mental/neurodevelopmental conditions, social injustice, or oppression may result in challenges for services in engaging and supporting people with multiple compound needs. These challenges may include appointments not being kept, thresholds not being met, behavioural issues, or ongoing substance use.

To promote engagement and involvement consideration should be given to any factors that may be influencing the organisation’s ability to engage with the person.  This should include any preferences the person may have regarding the location, timing, and format of meetings as well as which professional(s) are best placed to engage and build relationships with them. Organisational engagement policies should be followed in the event of ongoing non-engagement.

Where the professional or organisation has difficulty in maintaining their involvement, there may be a requirement for advocacy to be considered. This could take the form of formal advocacy but could also be through a support worker or navigator role.

2.9.4. Legislation

There is a range of legislation that needs to be considered by professionals and organisations supporting and safeguarding those with multiple compound needs. Learning from local Safeguarding Adult Reviews has shown missed opportunities to identify and respond abuse and neglect experienced by this group of people.

Care Act

The Care Act includes a clear legal framework for how local authorities and other parts of the system should protect adults with care and support needs that are experiencing, or at risk of, abuse or neglect. It defines adult safeguarding as protecting adults rights to live in safety, free from abuse or neglect. There are specific adult safeguarding duties under section 42 that apply to any adult who is 18 years or over who:

• has care and support needs and
• is experiencing, or at risk of, abuse and neglect
• is unable to protect themselves from the abuse or neglect

There are ten categories of abuse and neglect identified within the Care Act, which includes self-neglect and domestic abuse. In situations where an adult with multiple compound needs is experiencing, or at risk of, abuse or neglect a formal safeguarding concern needs to be raised with the relevant local authority.

The Brighton and Hove, East Sussex and West Sussex SABs have developed pan-Sussex Safeguarding Adults Threshold Guidance (PDF, 766KB), which provides advice and support on the identification of safeguarding, including domestic abuse.

Mental Capacity

In supporting and safeguarding people with multiple compound needs there may be a range of factors that potentially influence decision-making, meaning accurate interpretation and application of the Mental Capacity Act (MCA) 2005 is vital.

Capacity is assumed but this presumption does not exclude the need to potentially explore capacity further. The Mental Capacity Act Code of Practice outlines situations where there may be cause for concern if someone makes unwise decisions that put them at significant risk of harm or makes a particular decision that is out of character. Any impairment of the mind or brain, whether temporary or permanent, that impacts on the person’s ability to make the decision also requires exploration of capacity.  

Robust mental capacity assessments are critical in determining the approach to be taken by professionals, either to support the decision-making of an adult with capacity or to intervene to protect the best interests of an adult who lacks capacity. Any mental capacity assessment must be time-specific and relate to a specific intervention or action. The assessment should be appropriately recorded.

When undertaking a mental capacity act assessment reliance must not be placed solely on what a person says where adverse experiences, possible exploitation, trauma, and prolonged substance misuse could be affecting behaviour. An example is the compulsion associated with an addictive behaviour that can be seen as overriding someone’s understanding of information about the impact of their alcohol use, which can imply a lack of capacity.

 In these instances it is good practice to consider carrying out joint mental capacity assessments, for example, involving others such as an occupational therapist or psychologist. They can assist with assessing the person’s functional ability to undertake related activities and executive functioning (see section on decisional and executive functioning).

It is important to clearly document how a professional has maximised the person’s autonomy and involvement within the mental capacity assessment, ensuring they have been given all practical support and information to help them reach a decision for themselves. In relation to multiple compound needs this will include exploration of the person’s understanding of their behaviours, associated risks and consequences of decisions they are making.

If a person is subject to coercion and control or undue influence by another person this may impair their judgement and could impact on their ability to make decisions about their safety.

Fluctuating capacity

Fluctuations in mental capacity can take place over days or weeks, or over the course of a day. Consideration should be given to undertaking a mental capacity assessment at a time when the adult is at their highest level of functioning.

Fluctuating capacity can be a feature of chronic dependence on alcohol. At some points, e.g. early in the morning, the adult may be less intoxicated and able to have a more coherent conversation. Later in the day they may be intoxicated again and unable to follow any actions they agreed during the earlier conversation.

Other adults may have a temporary impairment of their ability to make decisions due to an acute infection. The key question in these situations is whether the decision can wait until the adult has received treatment for the infection. In emergency situations, it is necessary to proceed with the best interests decision making process.

For adults who have ongoing fluctuating capacity, the approach taken will depend on the ‘cycle’ of the fluctuation in terms of its length and severity. It may be necessary to review the capacity assessments over a period of time.

In complex cases, legal advice should be sought.

Decisional capacity and executive functioning

SCIE report 46 ‘Self-neglect and adult safeguarding: findings from research’ highlights the difference between capacity to make a decision (decisional capacity) and capacity to actually carry out the decision (executive functioning or capacity).

Good practice includes considering whether the adult has the capacity to act on a decision they have made (executive functioning).

Where decisional capacity is not accompanied by the ability to carry out the decision, overall capacity is impaired and interventions by professionals to reduce risk and safeguard wellbeing may be legitimate.

Frontal lobe damage is an example of a condition which may cause loss of executive brain function, resulting in difficulties with understanding, retaining, using and weighing information, and therefore affects problem solving and the ability to act on a decision at the appropriate point.

It is also important for those supporting an adult with multiple compound needs to have insight into their own values and beliefs in order to avoid any bias against what could be perceived as unwise decisions and behaviours.

Unwise decisions

Principle 3 of the MCA enshrines a person’s right to their own values, beliefs, preferences and attitudes. However, this right does not absolve an agency from their duty of care, and anyone supporting an adult who is self-neglecting must ensure they have met their professional responsibility.

Where an adult has capacity and may be making what others consider to be an ‘unwise decision’ does not mean that no further action regarding the self-neglect is required, particularly where the risk of harm is deemed to be serious or critical.

The duty of care extends to gathering all the necessary information to inform a comprehensive risk assessment. It may be determined that there are no legal powers to intervene. However, it will be demonstrated that the risks and possible actions have been fully considered on a multi-agency basis.

It is also important for those supporting an adult with self-neglecting behaviours to have insight into their own values and beliefs in order to avoid any bias against what could be perceived as unwise decisions and behaviours.

Inherent Jurisdiction

Taking a case to the High Court for a decision regarding interventions can be considered in extreme cases of self-neglect, i.e. where a person with capacity is:

• at risk of serious harm or death, and
• refuses all offers of support or interventions, or
• is unduly influenced by someone else

The High Court has powers to intervene in such cases, although the presumption is always to protect the adult’s human rights.

Legal advice should be sought before taking this option and for further information on inherent jurisdiction please see inherent_jurisdition_pg_web.pdf (researchinpractice.org.uk) (opens in a new window).

Best Interest decision-making

If a person is assessed as not having capacity to make a specific decision any subsequent decisions or acts should be made in their best interests.

Any best interests decisions should be taken formally and involve relevant professionals and anyone with an interest in the adult’s welfare, such as family. Additionally, consideration should be given as to whether an Independent Mental Capacity Advocate (IMCA) should be instructed.

Best interests must be determined by what the person would want were they to have capacity. “Lacking capacity is not an off switch for freedoms” (Wye Valley NHS Trust v Mr B, 2015, EWOCP 60). Therefore, any previous relevant views or behaviours must be considered when looking at the less restrictive options to keep the person as safe as possible. 

If there are difficulties in making a best interests decision, it may be necessary to seek legal advice. In particularly challenging and complex cases, it may be necessary to make a referral to the Court of Protection for a best interests decision. Any referral to the Court of Protection should be discussed with Legal Services, including where there may be a ‘reasonable belief’ of lack of decision-specific capacity in situations where an adult is not engaging or refuses an assessment.

Domestic Abuse Act

Domestic abuse is one of the five specific needs classified as multiple compound needs. The definition of domestic abuse is set out in the Domestic Abuse Act 2021.It gives police, local authorities, and the courts wider powers and greater accountability to protect those experiencing domestic abuse. It uses the term domestic abuse rather than domestic violence in encouraging people to consider that domestic abuse can present in many ways and is not just classified as physical violence.

For more information on domestic abuse please refer to chapter 2.7.

2.9.5. Multi-agency working

It is likely that in supporting and safeguarding people with multiple compound needs more than one organisation will come into contact with the person, with different organisations holding a range of knowledge, information, and expertise.  

Involving all those in contact with the person enables shared responsibility and a co-ordinated approach to be developed leading to improved planning, in creating a flexible and creative approach that assists the person to achieve positive outcomes.

It requires whole system partnership working across mental health and substance misuse providers, councils, adult social care, police, housing and homelessness services, primary care and secondary health care.

In situations where there is significant risk consideration should be given to a Lead Professional role. This can be undertaken by any professional involved and specific tasks may include; ensuring the views of the person are captured, making onward referrals, ensuring review meetings and planning takes place, and sharing information to keep all those involved updated.

There are a number of key considerations and steps in taking a multi-agency approach to supporting and safeguarding people with multiple compound needs.

Communication and information-sharing

Effective communication and information-sharing is vital to enable professionals to develop strong working relationships and networks, trust, and shared ownership of decisions and risk management when supporting an adult with multiple compound needs.

When working together, professionals from across different organisations should seek to understand and respect each other’s roles in supporting the adult, as well as offering the flexibility which may be required to gain the best possible outcome for the adult. This will help to set expectations, clarify responsibilities; and avoid any misunderstanding when sharing work.

Confidentiality is an important principle that enables people enables people to feel safe but the right to confidentiality is not absolute. If an adult refuses consent to share information, their wishes should be respected but there are instances where the sharing of information can still legally take place when it is necessary to do so, and there are adequate safeguards in place to protect the security of the information.

The Brighton and Hove, East Sussex and West Sussex SABs have developed a pan-Sussex Information Sharing Guide and Protocol (PDF, 321KB), which provides further information in relation to information sharing.

Multi-agency meetings

Multi-agency, or disciplinary, team meetings (MDT or MDM) are the best way to ensure there is effective information sharing and communication, as well as a shared responsibility for assessing risks to the adult and agreeing an action plan to aim to mitigate these risks.

It is often assumed that the Local Authority are responsible for leading on the multi-agency response. However, it is important to note that any agency can convene an MDM/MDT meeting; this could be the agency who identifies risk and has primary involvement or the best relationship in supporting the person. If there is an open section 42 safeguarding enquiry the local authority need to be informed.  

A meeting should be convened when:

• Interventions to date have not reduced the level of risk and significant risk remains, and
• The level of risk requires formal information sharing and for a multi-agency plan to be agreed.

Multi-disciplinary meetings should have a clear agenda addressing the areas which need to be covered, a comprehensive record of actions agreed and who is responsible for each of these, with clear timescales.

When actions and responsibilities are agreed within an MDM/MDT meeting, these must be clearly documented within the adult’s care records; this could include within their case notes, care plans, or risk assessments. This evidences what is being done to mitigate risk to the adult.

If an MDM/MDT meeting is not possible to convene, the work needed between professionals should still take place and this could be achieved virtually or via calls/emails to all agencies involved to gain the information needed, advice and to agree actions. The lead agency working with the adult would take this forward.

If there is a disagreement between professionals across agencies in the approach to an adult’s care, you should refer to our Sussex Safeguarding Escalation and Resolution Protocol (PDF, 214KB), which supports consistent and timely decision-making in relation to adult safeguarding. The protocol includes guidance in relation to mental capacity issues and safeguarding and has a streamlined escalation process that explicitly ensures relevant safeguarding leads are consulted at an appropriate point.

Multi-agency risk assessment

Risk assessment is the process of working with an adult to maximise safety and to reduce future risk. It is an integral part of safeguarding, and professionals should adopt a flexible solution-focussed approach to mitigating risk.

Situations involving significant risk often require a multi-agency approach, underpinned by clear and timely information sharing and shared risk-assessing resulting in multi-agency risk management plans. These should be proportionate and focussed on preventing, reducing, or eliminating the future risk of harm. Risks can be evaluated through MDM/MDT meetings and should be reviewed regularly to reassess the level and nature of the risk.

Risk assessments and risk plans should clearly record:

• all known and anticipated risks
• the adult’s views and wishes
• what action is being taken and by whom
• any issues with mental capacity and how this is to be addressed including the need, where appropriate, for best interest decisions
• how the understanding of risk and the actions available to support is shared with the adult.

In West Sussex and East Sussex there are Multi-agency Risk Management (MARM) protocols that should be considered when working with adults with multiple compound needs who remain at high risk of harm despite previous interventions. For further information on MARMs please go to either the West Sussex SAB or East Sussex SAB website:

• Home | East Sussex SAB (opens in a new window)
• Home | West Sussex SAB (opens in a new window)

For further information on multi-agency working please refer to section 1.1.3.