Provider report for Safeguarding Enquiry

Date of report
Name of Provider Service
Author of Report
Job role
Address/Contact details
Name of Adult
Address
Date of Birth
Name(s) of person allegedly causing harm
Relationship to adult
Job role ( if applicable)
Does the Adult have mental capacity to take part in the enquiry
Name of family member/ advocate if adult has substantial difficulty in expressing their views about what happened.
Contact details
  1. Personal background
Brief medical history/ care needs, relationships, support network
  1. Details of the safeguarding concern?
When ( date/time) and where did it take place
Brief factual details of incident/concern
Who was involved and how.
Description of injury/ harm/ distress caused to the adult
.
  1. Views of the adult/family member/advocate
How did the incident/concern make them feel, What does the adult want to happen in response to the incident/concern ( their outcomes) - their views are important
  1. Summary of evidence
Date and Brief summary of interview with person allegedly causing harm
.
  1. View whether abuse or neglect is substantiated
Include brief details of the evidence of why
.
  1. Action Plan
What has been put on place or been changed to prevent a reoccurrence of the incident/concern
Please list actions, including by whom and timescales for completion ( i.e. change to care plan, training for staff, audit, increased monitoring etc.)
ACTION / NAME OF PERSON RESPONSIBLE / TIMESCALES
  1. Actions for person alleged to have caused harm.
Please give details (ie disciplinary procedures, increased monitoring or supervision, training, referral to DBS or regulatory body). Please include dates of completion.
ACTION / TIMESCALE
  1. Feedback from adult/family/advocate
Have the outcomes stated by the adult been achieved? Is the adult or their representative satisfied with the outcome? If not, why not and what is the plan to address this?
  1. Review date
If needed

Once completed, please send securely via email to

or by post to

Adult Care, Floor 3, No1 Riverside, Smith Street, Rochdale OL16 1XU

Adult Care:- on receipt, please upload onto ALLIS in the safeguarding module and forward to the Manager of the appropriate team, who should acknowledge receipt with the author and confirm whether the safeguarding concern has been adequately addressed. If so, the Manager needs to complete the Safeguarding closure summary on ALLIS.

This form should then be forwarded to the Commissioning Team for quality assurance purposes.