SAFEGUARDING ADULTS CONCERN FORM - Confidential
Please complete all Questions or note as ‘not applicable’
PLEASE ENTER YOUR DETAILSForm Start Date
Title / MrMrsMissMsOther
First name / Surname
Job title / Telephone contact
number
Email address
PLEASE ENTER THE DETAILS OF THE ADULT AT RISK
CareFirst ID
Family name / Given name
Date of birth (dd/mm/yyyy) / Gender
Main address
BACKGROUND INFORMATION
NHS Number (mandatory)
Is the Adult at risk already known to Adult Social Care? (mandatory) / YesNo
Enter Adult at Risk’s current address if this is different to the main address above
Has this Adult at Risk been placed in Newham by another Borough? / Yes / No
Type of Accommodation / Adult placementBad & breakfastMobile accomodations (other)ExtracareEx offenders (e.g. probabtion hostel)Living with family / friendsHospiceHospital / NHS facilityIntermediate careMobile (gypsy, traveller, Roma)Night shelter / hostelNursing homeOtherOwn homePrison / other criminal justice facilityRefugeResidential homeRough sleeperSheltered accomodationSupported accomodationOther temporary accomodationTemporary accomodation (LA)
Religion (mandatory) / AtheistBaha'lBaptistBuddhistChurch of EnglandHinduInformation not yet obtainedJainJehovah's witnessJewishMethodistMuslimNoneOtherOther ChristianOrthodox JewishRoman CatholicSeventh Day AdventistShintoSikhZoroastrian / Pharsi / Ethnicity
(mandatory) / AfricanArabAsian otherBangladeshiBlack otherCaribbeanChineseEastern EuropeanGypsy / RomaIndianInformation not yet obtainedMixed otherPakistaniRefusedSomaliSri Lankan TamilTraveller or Irish HeritageWhite and Asian (Mixed)White and Black African (Mixed)White and Black Caribbean (Mixed)White BritishWhite IrishWhite Other
Marital Status (mandatory) / Short Term Primary Support Reason / Access and mobilityAsylum seeker supportDomestic violenceLearning disability supportMental health supportpaediatric referralpersonal care supportsubstance misuse supportsupport for dual impairmentsupport for hearingSupport for social isolation / otherSupport for visualSupport for carerSupport with memory and cognition
Primary Support Reason (Long Term) (mandatory / Physical support - Access & Mobilty Physical Support - Personal Care Support Sensory Support - Support for visual impairmentSensory Support - Support for hearing impairmentSensory Support - Support for Dual ImpairmentSupport with memory & cognitionLearning Disability SupportMental Health SupportSocial Support - Support to carerSocial support - Substance Misuse supportSocial support - Asylum seeker supportSocial Support - For social isolation/Other
Communication needs / American Sign LanguageAudiaB.S.L SignerBlissBlock AlphabetBrailleClear SpeechClear Speach/Lip ReadingCommunication Board or BookCannot ReadContact by phone (Type Talk)Deaf/Blind ManualEmotional SignalsEasy ReadElectronicFacial ExpressionHome generated signsInnumerateLanguage LineLarge printLip readingLoopMakatonMinicom
Detail language and/or any other forms of communication not mentioned above
Long Term Health Condition (mandatory) / AutismAsperger's Syndrome/High functioning AutismChronic obstructive pulmonary disease (COPD)CancerAcquired Physical InjuryHIV/AIDSStrokeParkinson'sMotor neurone disease (MND)Acquired brian injuryPhysical OtherNeurological OtherVisually ImpairedHearing ImpairedSensory Impairment - OtherLearning DisabilityLearning/Development/Intellectual Disability otherDementiaMental Health Condition OtherNo relevant long term health conditions
DETAILS OF ALLEGED INCIDENT
Date of Concern(mandatory) / Date of alleged incident (mandatory)
Time of alleged Incident
Location of alleged risk(mandatory)
Please provide details of where this happened e.g. name of Home / Acute HospitalAlleged Perpretrators HomeCare Home - PermanentCare Home - TemporaryCare Home With Nursing - PermanentCare Home With Nursing - TemporaryCommunity HospitalDay Centre/ServiceEducation/Training/WorkplaceEstablishmentMental Health Inpatient SettingNot KnownOtherOther Health SettingOwn HomePublic PlaceSupported AccomodationService within the community
Is the Concern against the provider? / YesNo
If yes, select type of provider (mandatory) / Acute NHS hospitals - OtherCCG - GP and staff, dentistsBarts Health - Newham HospitalELFT - Mental HealthELFT - Community Health Local AuthorityPrivate HospitalsPVI - Care AgencyPVI - PlacementsSupported Living
Advise on name of provider, dependant on the type selected above (mandatory)
Description of Alleged Incident (including where the alleged abuse took place and any injuries caused to include witnesses) (mandatory)
Type (s) of alleged abuse (mandatory)Choose:
- Physical Abuse
- Sexual Abuse
- Psychological Abuse
- Financial or Material Abuse
- Discriminatory Abuse
- Organisational Abuse
- Neglect and Acts of Omission
- Domestic Abuse
- Sexual Exploitation
- Modern Slavery
- Self-Neglect
- Pressure ulcer
If this is an incident of domestic abuse, state which type of domestic abuse? Choose:
- Domestic Abuse
- Faith based Abuse
- Female Genital Mutilation
- Forced Marriage
- Honour Based Violence
- Sexual violence
What relevant domestic abuse actions were taken?
(mandatory)
Provide Police ref no. if the Police have been informed
Any other information relating to the incident, including all witnesses
DETAILS OF PERSON (S) ALLEGED TO HAVE HARMED
Name of Person alleged to have harmed
If the Person alleged to have harmed is an Adult at Risk please enter their CareFirst ID Number (if known)
Contact details (if known)
Relationship of the Person alleged to have harmed to the Adult at Risk
Is the Person alleged to have harmed the Adult at Risk’s main Carer?
YesNo / YesNo / YesNo
Does the Person alleged to have harmed live with the Adult at Risk?
YesNo / YesNo / YesNo
Is the Person alleged to have harmed aware of the Referral/Concern?
YesNo / YesNo / YesNo
Any other information relating to the Person alleged to have harmed
CARE SUPPORT PLAN DETAILS
What type of care/support plan does the Adult at Risk have? Choose:
- Commissioned Care Plan
- Commissioned Care Plan – Other LA
- Direct Payment
- No Care Plan
- Self Directed Support
- Self Funded
Select the main provider who has responsibility to define the service/care/support plan? (mandatory)
Guidance: Ensure there is a professional relationship to reflect this provider if applicable on customer records
Choose:
- ELFT MH
- Health – BARTS
- Health – Community
- LBN Social Care
- No Care Plan
- Substance Misuse
- Health CCG (GPs)
MENTAL CAPACITY & CONSENT
Does the Adult at Risk have capacity in regards to the Safeguarding issues? (mandatory) / Yes / No / N/K
Does the Adult at Risk consent to the use of the safeguarding process and information sharing across agencies as necessary? (mandatory) / Yes / No / N/K
What is the Adult at risk’s or their representative(s) desired outcome?
Does the Adult at Risk require an Advocate or IMCA? (mandatory) / Yes / No / N/K
NEXT OF KIN & GP DETAILS
Next of Kin (NOK) / GP
Relationship (NOK) / Practice Name
Tel no / Tel no
Address / Address
Email address / Email address
DETAILS OF PERSON NOTIFYING ALLEGED ABUSE
Details of Person who notified the alleged abuse (mandatory)
List name; address and all contact details (telephone/email)
Type of person/organisation who raised the Concern? (mandatory) / Care quality commissionDay care staffDomiciliary care staffEducation/Training/Workplace establishmentFamily memberHousingNeighbourOtherOther service userOther social care staffPolicePrimary/community health staffProbation/Other criminal Justice systemResidential health staffSecondary health staffSelfSelf directed care staffSocial worker/Care Manager
INTERIM SAFEGUARDING PLAN
Summary of Actions and Risks
Brief Description of Action taken so far (to include details of interim safeguards)
ANY OTHER INFORMATION / COMMENTS
The information you have provided will be assessed by Adults Social Care services and the next steps decided. It is likely that you will be contacted for clarification or outcome so please ensure your contact information is correct. If this information is for notification purposes only please ensure this is noted in the further comments box.
Please first save your completed Concern Form then:
Either send as an attachment by email to
(to open an email to this address click on the address while also holding the ctrl key on your keyboard)
Or fax it to: 0203373 4158
Page 1 of 4Updated July 2016