The name of the service user mentioned in this article has been changed
Situation: Maurice Anderson, 63, lives in a basement bedsit, where much to his landlord’s frustration he has a secured tenancy. He has lived alone for 37 years and has not worked for the past 30 years. The privately owned house above the basement began being rented to overseas students about 15 years ago. From this time Maurice has had no access to the upstairs facilities, including bathroom.
Problem: Two Ghanaian students in the house upstairs have been visiting Maurice, bringing him food, newspapers and library books. Although they were concerned about the conversations he regularly has with people who are not there and that he often sees wild animals in the room, they simply thought him an eccentric old man. On one visit, they were worried about some cuts on his arms and called the GP. On visiting, the GP contacted social services describing Maurice’s living conditions as “atrocious”. He has a leaking toilet but no bath or shower. There is no hot water and no natural light. He spends 24 hours in his chair, reading all day and sleeping all night. The emergency duty team worker found that Maurice could be coherent and was clear that he didn’t want to leave – even to go to hospital: this was and always had been his home. However, he did hallucinate during the visit. There was no sign of any medication, nor evidence of any drug or alcohol use. The EDT worker has referred Maurice to the community mental health team.
PRACTICE PANEL (Milton Keynes Primary Care Trust)
David Glover-Wright, Team Manager, Community Mental Health Team ; Jane Ross, Community psychiatric nurse ; Kathie Price, Community psychiatric nurse ; Kate Vaughan, Substance misuse outreach worker ; Steve Caffrey, Team Manager – community mental health team
David Glover Wright
Maurice’s physical well-being seems to be more of an issue than his mental health needs. He seems to be living in poor conditions but essentially, seems happy with his lot. Questions about capacity and the right to self-determination immediately come to mind; if he is choosing to live in such an environment and has the ability to understand and explain his circumstances then why can’t he continue to live in such conditions?
It is often difficult for statutory agencies to “allow” someone to live in such conditions once they come to light. It could be that intervention is required to determine whether he has any social care needs. An assessment under the NHS and Community Care Act 1990 might reveal a number of “eligible” needs which need further follow-up. Pressure needs to be brought to bear on his landlord who appears to be neglecting his duties to maintain Maurice’s accommodation. It could be that the accommodation might be deemed uninhabitable by the local environmental health team who could then require the landlord to make necessary alterations.
Emergency duty teams are usually very adept at undertaking risk assessments to determine if urgent intervention is required or whether “a situation can wait until the next working day”. EDT workers generally do not visit to undertake assessments unless there are serious concerns which require out-of-hours intervention.
In this case the social worker is prepared to hold-off any major plan of action and Maurice can be left until day time services are contacted.
The community mental health team might not necessarily be the best place to start with Maurice’s situation; it could be that Maurice would feel stigmatised by the assumption that he was mentally unwell and requiring “treatment”.
Should Maurice choose not to accept help, then consideration would need to be given to supporting and encouraging him through slow and gradual engagement, perhaps through a community support worker. Maurice clearly has an interest in books and this might provide a useful access point to engage with him in a positive and helpful manner while at the same time begin to address his practical needs.
The starting point should be to discuss the emergency duty team assessment. We have good links with our local emergency duty team, but it is not always possible to discuss the situation with the worker concerned, given their operational shifts. It could be that brief details recorded on an initial assessment form raise more questions than answers. It could also be that the GP had assumed the EDT would immediately arrange admission to a social care establishment rather than leaving him in his flat.
I would consider an urgent joint assessment with my social work colleague given the GP’s concerns and the conclusions reached by the EDT. There are immediate questions about possible self-harm or self-neglect leading to the cuts on his arms. Our visit would involve gaining his confidence and promoting some understanding to his situation. We would assume that he would be willing to accept a visit. However, he might be reluctant to accept our help.
We would seek to undertake a risk assessment and consider with him issues of neglect, any self-harming behaviour, his living environment and its impact on his physical health. Research has shown there are regular physical health care needs in people with long-term mental health problems which are not always picked up.
Clearly there are pressing environmental concerns, the leaking toilet might have created insanitary conditions heightening the risk of disease. Maurice seems to be mentally “unwell” but he may have developed a way of coping with his symptoms and has created a lifestyle where he can manage them. Disturbing his routine and lifestyle through radical intervention might make his mental health worse.
We would need to liaise with housing to address the landlord’s attitude to Maurice. In Milton Keynes we have a specialist housing liaison officer who works with service users and professionals alike and acts as a troubleshooter in situations like this.
If Maurice doesn’t want our support and intervention I would suggest an advocate to work alongside him and gain his confidence. Our risk assessment might lead us to choose more direct action if he lacks capacity to understand his circumstances.
While there is much the services could offer Maurice, the initial emphasis should be on building up a rapport and establishing trust, writes Kay Sheldon.
The services should reassure Maurice that they are not going to remove him from his home: he has clearly stated that he wants to remain where he is.
Maurice has lived a very isolated existence for a long time and although he has clearly not minded visitors, it may take some time for him to get used to more intense input. Maurice may appreciate the help of some kind of support worker, starting off with the sort of input Maurice has already accepted from the students, such as bringing food and books. This could be extended to encouraging Maurice to go to the shops or library with the support worker.
Consideration should be given to the background of the support worker and Maurice’s preferences in this respect. For example, Maurice may feel more comfortable with an older male support worker.
As and when Maurice is ready, other help could be offered. Maurice’s living conditions are appalling, in particular the leaking toilet and lack of hot water. It seems that his landlord is not providing an adequate level of accommodation. Legal advice on the landlord’s statutory obligations should be sought and discussed with Maurice.
Maurice may well have some physical health problems and should be encouraged to have a full check-up as soon as possible. This, in itself, could have a positive effect on his mental health. His visual and auditory hallucinations should be discussed with him to discover his views on them. There is no doubt that social isolation can exacerbate, or even cause, hallucinations, and if Maurice was able to become more socially integrated, this may well reduce the hallucinations.
In time, Maurice could be encouraged to get out and about more and to pursue any interests he may have. This could be through clubs or adult education or, if necessary as an interim step, by attending a day centre or other community mental health resource. It may be worth asking Maurice if he has any family and, if he wishes, could be helped to contact them.
Other help that Maurice may appreciate could be helping him to improve his living conditions. This could either be by working with Maurice and/or arranging help with cleaning and decorating. It would be worth tactfully enquiring about Maurice’s financial situation and to check whether he is receiving all the financial help he may be entitled to.
Kay Sheldon is a mental health service user