Safeguarding Adults Concern Form

Multi-Agency Safeguarding Hub Tel: 01325 406111

Secure e-mail:

IF A CRIME HAS BEEN COMMITTED HAVE THE POLICE BEEN INFORMED

Please refer to Guidance Notes to complete each part of this form

Please complete using block capitals and black ink.

Part 1: About the Adult at risk of harm or abuse

Name: / Date of Birth:
Gender:
(M/F) / Client ID:
(If Known) / Client Group
(Office Use) / Ethnicity:
Address: / Telephone:
Funding:
Is the adult at risk residing in an out of authority placement / Yes / No
Name and contact details of out of area authority:
Name and contact details of other authority named worker:
Please identify who is funding any care and support provision?
Own Council (i.e. DBC) / Other Local Authority area
Funded by Health / Self-Funded
Both Health and Local Authority / No Services
(This section is about the adult at risk and includes a section for their views, wishes, feelings and beliefs in relation to the concern, information must be provided.
The Mental Capacity Act principles state “a person must be assumed to have capacity unless it is established that he lacks capacity
Do you have concerns about the capacity of the adult at risk to consent to this safeguarding concern being reported? You must record an answer (refer to Guidance notes) / Yes / No
If you have ticked YES please give details.
If adult at risk has capacity please indicate if this concern is being submitted under either Public or Vital Interests (see guidance)
Has consent for this concern report been obtained? You must record an answer. / Yes / No
Is the person aware of the concern being shared? You must record an answer. / Yes / No
Is a capacity assessment required? / Yes / No
Is there an Advocate/IMCA or IMHA already involved. / Yes / No
If you have ticked YES to an advocate/IMCA or IMHA involvement. Please provide details of their name and contact number.
If a referral to advocacy is required, has this referral been made
(Please provide details) / Yes / No
Has the person/carer/family member or advocate been fully involved
in the discussions around raising the safeguarding concern? / Yes / No
If not please give details as to why.
Initial views and wishes of the Adult at Risk (refer to guidance notes)
(This should be what the adult at risk or their representative would like to happen in relation to the safeguarding concern being raised, e.g. what outcomes would they like)

Part 2: About the Reporting Person/ Organisation

Reporter Name: / Organisation Name:
(If Organisation)
Address: / Telephone:

Relationship of Reporter to the Person experiencing harm or abuse (Please select the most appropriate option):

Ambulance Service / Neighbour
Care Quality Commission / Other
CCG Service e.g. CHC/Dentist / Other External Agency/Provider
Children’s Services (DBC Internal) / Other Service User
Community Health e.g. District Nurse / Other Local Authority
Councillor/Council Member / Pharmacist
Education/Workplace/Training Setting / Police
Family e.g. partner, carer / Police Community Safety Officer (PCSO)
Family Friend / Private Housing Provision (e.g. Association)
GP / Self
Health – Urgent Care / Social Care Day Care Staff/Day Centre
Health Visitor / Social Care Domiciliary Staff
Hospital – Base Ward / Social Care (Other)
Hospital – A & E / Social Care Residential Staff (Care Home)
Hospital – Other / Social Care Self-Directed Care Staff
Housing DBC (Internal) / Social Care – Social Care Worker/Care Mgr
Member of Public / Supported Living Setting
Mental Health - External / Voluntary Service

Part 3: About the alleged harm or abuse

Date of the Concern: / Date the Alleged Abuse took place:

(More than 1 category may apply – please ü all that apply)

Discriminatory / Psychological / Financial / Domestic Abuse
Physical / Organisational / Sexual / Self-Neglect
Modern Slavery / Neglect

Location of Alleged Abuse – (More than 1 location may apply – please ü all that apply)

Care Home / Other
Community Service / Own Home
Hospital
Reported Circumstances of Concern
(Please provide a clear, factual narrative of the concerns and refer to guidance notes).
Has appropriate/immediate action been taken to safeguard the Adult at risk of harm or abuse? (Identify and record below all immediate action to ensure their safety and wellbeing)
Have any safeguarding concerns been reported about the adult at risk of harm or abuse in the last 12 months / Yes / No
Details of Person(s)/Organisation(s) alleged to have caused harm or abuse (see guidance notes)
Name / Address/Telephone / Date of Birth / Relationship to Adult at risk

Part 4: Organisations Only – Additional Information

Have the CQC or the DBS been informed? (see Guidance Notes) / Yes / No
Please provide details:
Have the police been informed? (see Guidance Notes) / Yes / No
Please provide details:
Has a GP/GP Practice been informed? (see Guidance Notes) / Yes / No
Please provide details:
Any other information that may bear relevance to this reported concern (for example, background history, body maps, records available and/or any previous concerns that were not reported for the Adult at risk or person(s) alleged to have caused harm or abuse.

Services for People – Adult Social Care

All concern reports should be sent to

Multi-Agency Safeguarding Hub (Adults) Telephone: 01325 406111

Minicom Telephone: 01325 468504 Text Phone: 07538 601527

Safeguarding Adults Team (For advice only) Telephone: 01325 406460/406461

Out of Hours Telephone: 08702 402994 (Out of Hours before 8.00am & after 5.00pm Mon to Thurs, after 4.30pm Fridays, Over Weekends)

Ref No 0433 - Rev No 12, Issue Date April 2015, Next Review Date 2016