Date and time concern raised: / Service User ID /
NHS No
SECTION 8. REFERRAL BACKGROUND
 New Referral Protection Plan already in place
Referred previously
SECTION 9. RISK ASSESSMENT
Please consider risk indicators below. If present, indicate if a Risk Management Plan (RMP) is required and detail actions required
Risk Indicators for Abuse / Y/N / RMP / Adult at Risk level of concern? High, Medium, Low?
Have there been previous concerns that impact on current situation?
Is the alleged abuser a carer of the person at risk?
Is there fear of reprisals from the alleged abuser or some other person?
Is the person at risk dependant on the alleged abuser for basic needs?
Does the alleged abuser administer medication to the person at risk?
Does the person at risk feel safe in their current environment?
Does the person at risk have fears about disclosing?
Is the person at risk isolated from family or friends?
Is the person at risk isolated culturally or religiously?
Are the person at risk’s coping strategies posing any increased risk e.g. substance misuse, suicidal thought?
Are there children in the household?
Do you need to talk to Children’s Services?
Are there any other persons at risk in the household?
Do you need to discuss with other relevant care managers/duty teams?
Are there any other risk factors not raised above?
Are there concerns about the cognition/comprehension or communication of the person at risk
Additional Risk Indicators for Self Neglect
Are there concerns about self neglect?
Are there concerns about the general living environment (include sanitary, general repair of building, heating etc)
Any Other Comments?
Section 10. MENTAL CAPACITY
Has the adult at risk been assessed for mental capacity to make decisions related to these concerns in line with Mental Capacity Act 2005 principles and Code of Practice?
[ ] Yes, was assessed and was lacking capacity
[ ] Yes, was assessed and has capacity
[ ] No, was not assessed because those who know them are all clear that they have capacity
Details:
Was the person supported by an advocate? (formal or informal) Yes / No
SECTION 11. RELEVANT PERSONS (identify other victims, witnesses/relatives/professional e.g. GP or anyone else who may be invited to a strategy meeting)
Title / Surname / Forenames / Address/Contact details / Connection to person at risk
SECTION 12. DISCUSSION WITH OTHER AGENCIES(Strategy discussion)
Agency / Person’s Name / Date / Time / Details
Police
Social Services
Health
Other
SECTION 13. OTHER ORGANISATIONS INVOLVED (Tick as applicable)
Police  Social Services Reading
Social Services West Berkshire Social Services Wokingham
Community Health Mental Health Trust
Other Local Authority Residential/ Nursing Home
Domiciliary/Homecare Agency Hospital
Housing Agency–please specify local authority Day Centre/Managing
 Other – please specify  CQC
(Note: Please bear in mind that in criminal cases of common assault (which includes minor injuries) that there is a time limit of six months from the date of the offence to the issue of a summons or charge.)
SECTION 14. MULTIPLE VICTIMS - ALERTS TO OTHER AUTHORITIES AND CQC
Are there multiple victims? Yes / No
Have other Local Authorities been alerted? Please give details:
Has the Care Quality Commission been alerted? / By whom: / Date:
SECTION 15. DETAILS OF SAFEGUARDING ASSESSMENT AND SAFEGUARDING ACTIONS TAKEN (include any additional information to that already provided in SECTION 2 of ALERT FORM)
In a criminal prosecution an “edited” copy of this form is discloseable. DO NOT enter personal opinions.
Review Date:
Has the initial referrer been informed of outcome? [ ] Yes [ ] No [ ] Anonymous referral
SECTION 16. CONSULTATION WITH MANAGER/SAFEGUARDING TEAM
Name of person completing form: / Organisation name: / Date:
Name of senior or manager making the decision: / Organisation name: / Date:
SECTION 17. OUTCOME OF REFERRAL
[ ] No Further Action / [ ] Inappropriate Referral

If it is agreed that a Strategy Meeting is required, please use Safeguarding Adults Strategy Meeting Form to record further action.If Strategy Meeting is not required, please complete SECTIONS 18- 21.

SECTION 18. CASE CONCLUSION (Tick one only as applicable):
Substantiated / Partially Substantiated
Not Substantiated / Inconclusive
Investigation Ceased at Individual’s Request

If the conclusion is unsubstantiated or not determined, this does not mean that actions cannot be taken to protect the person at risk in the future.

SECTION 19a. RESULT OF ACTION TAKEN TO MANAGE IDENTIFIED RISK (Tick one)
Risk identified and action taken / Risk identified and no action taken
Risk - Assessment inconclusive and action taken / Risk - Assessment inconclusive and no action taken
No risk identified and action taken / No risk identified and no action taken
Enquiry ceased at individual's request and no action taken
SECTION 19b. WHERE A RISK WAS IDENTIFIED, WHAT WAS THE OUTCOME / EXPECTED OUTCOME WHEN THE CASE WAS CONCLUDED? (Tick one)
Risk Remained [ ] Risk Reduced [ ] Risk Removed [ ]
SECTION 20. OUTCOME for PERSON AT RISK/PROTECTION PLAN (Tick any as applicable)
Protection Plan offered  Increased Monitoring
Removed from property/service  Community Care Assessment & Services
Civil Action  Application to court of Protection
Application to change appointee-ship  Referral to Advocacy
Referral to Counselling  Moved to increase/Different care
Management of Access to Finance  Guardianship/Mental Health Act
Review of Self Directed Support  Other
Restriction or management of Access of person at risk to alleged perpetrator
Referral to MARAC
 No further Action
SECTION 21. OUTCOME for ALLEGED ABUSER/ORGANISATION/SERVICE (Tick as applicable)
Criminal Prosecution /Formal caution  Police Action
Community Care Assessment and Services  Perpetrator removed from Property/Service
Management of Access to the person at risk  Referred to ISA
Referred to Registration Body  Disciplinary Action
Action by CQC  Continued Monitoring
Counselling/Training /Treatment  Referral to Court Mandated Treatment
Referral to MAAPA  Action under Mental Health Act
Action By Contract Compliance  Exoneration
Other  No further action
SECTION 22a. WAS THE INDIVIDUAL OR THEIR REPRESENTATIVE ASKED WHAT THEIR DESIRED OUTCOMES WERE?
Yes they were asked and outcomes were expressed / Include person’s comments. (If no comments received or individual’s desired outcomes were not met, please state why?)
Of these, were the desired outcomes:
Fully Achieved [ ] Partially Achieved [ ] Not Achieved [ ]
Yes they were asked but no outcomes were expressed
No [ ] Don’t know [ ] Not recorded [ ]

Details of investigation can be found:

SWIFT  RAISE  FWi  MOSAIC  ID No. (If applicable):

Paper file  Location:

Other Reference:

West of Berkshire Safeguarding Adults Referral Form Part 1 for use from 1st April 2016 to 31 March 2017

Date due for review December 2017

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