STRICTLY CONFIDENTIAL

Date of Concern: Time: Completed By:

1. Person at risk of harm information:
Name: Male: Female:
ID NO: e.g. SWYFT/MARISIS/NHS/CAREFIRST/ERICA, etc
NHS No. / Date of Birth:
Current Address: / Ethnic Origin:
Service user group:Primary one Only
Zero based definition: Learning Disability Support Mental Health Support
Access and Mobility Only Personal Care Support Support with Dual Impairment

Support with Hearing Impairment Support with Visual Impairment

Asylum Seeker Support Substance Misuse Support Support for Carer
Support for Social Isolation or Other Support Support with Memory & Cognition

2a. Alleged Abuse: More than one category may be applicable
Category of abuse: Physical Sexual Neglect or Acts of Omission
Financial/Material Organisational Discriminatory Psychological

Domestic Violence/Abuse Modern Slavery Self Neglect Sexual Exploitation
Hate Crime Mate Crime Radicalisation Female Genital Mutilation
Cyber Abuse Honour Based Violence Forced Marriage
Give details: Full names and titles should be used when refering to any other professionals, carers etc.This is the first information the reader sees so it must make sense.
2b.Does the Safeguarding concern relate to any of the following themes and trends:
Please tick whichever apply

Resident on Resident
Environmental Concerns (issues caused by the living environment and equipment)
Infection Control Issue
Pressure sore
Medications management
Practice Concern (issues resulting from staff and management practice or procedures)
Whistleblowing (issues raised by service staff which impact upon service delivery to Clients)
Moving and Handling
Fall

3. Safeguarding Adults concern raised by: Was the referral anonymous: Yes / No

Name(Full Name) :
Address:
Contact Number (Essential): / Role:/Relationship
Organisation:
Email Address: Fax:

4. Source of alleged harm information (person/organisation/Relationship to adult at risk etc.): If any of this information is not known then state why it’s not known do not leave blank.

Name: Male: Female:
Date of Birth: Ethnic Origin: / Organisation:
Address:
Contact No: / Relationship to Adult at Risk:
Previous History of alleged or proven abuse:
5. alleged source of harm
Isthe alleged source of harm aware of the Safeguarding Concern? Yes No
If Yes please give details: If Yes this must be completed, as it should only be in exceptional circumstances that the alleged Source of Harm is aware.
5b. Drugs and Alcohol
Were drugs or alcohol involved within the incident:
With reference to the person at risk? Yes No

With reference to the source of harm?: Yes No

Was Domestic Violence/Abuse a factor in this safeguarding concern:
Yes
If yes Consider & complete (DASH)
( Please see local Guidance to the location of this document and the actions appropriate to the level of risk identified) Guidance can be sought from the local Hate & Hidden Crime Officer

No
If a crime has been committed/suspected has this been reported to the police:

Yes No
If yes give details of whom the concern has been reported to and their contact details
To Who:
Contact Details:
If No
If the concern has not been discussed/reported to the police please give a detailed explanation
6. Details of Safeguarding concerns and initial response:
Please include a summary of your initial assessment/risk assessment/ immediate actions taken to protect the individual/individuals involved.
Please ensure you have considered all criteria in reaching a decision as to whether the 3 point test has been met:
The safeguarding duties apply to an adult who:
  1. has needs for care and support (whether or not the local authority is meeting any of those needs) and;
  2. is experiencing, or at risk of, abuse or neglect; and
  3. as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
All the following should be considered and evidenced within the text when assessing the alleged abuse and the risks related to the abuse of the individual and others where appropriate:
Level of threat to the person at risk’s physical well-being
The nature/extent of the abusive acts
Whether the abuse was a one off event or part of a long standing relationship or pattern
The impact of the abuse on the adult and their independence
The intent of the alleged source of harm – Is thisa potential hate crime
The risk of the abuse being repeated to the adult at risk, other adults or children. (Consider a risk assessment and referral to services if appropriate)
The risk that harm would result if no action was taken
If the incident involves a regulated service provider (inform Care Quality Commission and Contracts)
Do the allegations involve “persons in position of trust” refer to DASM*1 (please refer to local guidance)
What steps have been taken to ensure any risks have been minimised
Ensure the immediate safety of the adult
Seek any immediate medical attention where required
Complete body map where appropriate
Consider the illegality of the alleged source of harm’s actions whether a potential crime has been committed and report to the police
Preserve any evidence
Do not alert the alleged source of harm
Is the adult safe now
Does anything more need to be done
Is there any signs or suspicions of duress or coercive control (see …….relevant section of the procedures)
7. Capacity and Consent
Give details below of your consideration of capacity and discussions re consent.
The following should be considered and evidenced within the text:
The 5 principles of the MCA 2005
An assessment of mental capacity to make a decision about the issue in question;
Remember capacity is viewed as decision specific
Consider the use of an IMCA or other advocate (see
Is there a Deprivation of Liberty Safeguard
Consent –
Has the Adult At Risk Given consent: Yes No
Is the adult making a free an informed choice (Assess whether the person is being subjected to coercion, undue influence, intimidation including physical threat or assault from others, including the alleged source of harm
Identification of any other factors influencing the person’s decisions, to work with professionals to reduce risks such as
mental health difficulties, financial difficulties, duress/coercion

Other

Consult with Manager? Yes No
Consult with Legal Services where required Yes No
8. Is an Advocate/IMCA Required? :
Is a Care Act advocate required:
If yes – has this met the substantial difficulty definition:
  1. Understanding relevant information
  2. Retaining information
  3. Using or weighing the information as part of engaging
  4. Communicating their views, wishes and feelings
(See…. For full definition)
Yes
No

Is an IMCA required
Yes
No

If yes - has this met the ADASS guidance
In line with ADASS guidance an IMCA should always be appointed for an adult who lacks capacity unless it will bring no additional benefits. Examples:-
For adults who are subject to harm from family members/friends an IMCA should always be appointed at the start of the safeguarding process
For adults who have supportive families/friends but who may be “risk adverse” i.e. would push for a 24 hour care solution an IMCA should be appointed to avoid a potentially unlawful deprivation of liberty
For adults who have supportive families/friends who will support the adult in line with their wishes and the appointment of an IMCA may result in distress to the adult, it would be appropriate not to appoint as it will bring “no benefits”.
Yes
No

Is there already an appropriate paid or unpaid advocate appointed/involved:
Yes
No

If yes give details
Name: Address:
Relationship to person at risk:
9. Are there any risk to others e.g. children or other adults:
Yes
No

If Yes Please give details:
The following must be considered and evidenced
The impact of the abuse on other adults and children
The risk of the abuse being repeated to the person at risk, other vulnerable adults or children.
If not applicable state why
10. Are there any other people dependent on the person at risk: (adult/child)
Yes
No

If Yes Give details:
Is a referral to Children Services required?
Yes
No

Give details of actions taken if yes;
Is a referral to adult services required?
Yes
No

If yes give details
11. Who else has been consulted in reaching the decision
Name / Role / Telephone number / Address/ Email
This is essential to know who to invite to Planning/Outcome
Meeting
12. Decision on Safeguarding Concern
Does the information provided meet the 3 stage enquiry test for Statutory S.42 Safeguarding Enquiry?
Yes
No

If No give reasons. Detail why this concern did not meet the three-stagetest
If No did you give any advice and Signpost to appropriate services if required
Yes
No

If Yes Give detail of any signposting provided and advice
Does the information provided meet the 3-stage enquiry test?
Yes

Having made the Enquiry decision which organisation/agency is best placed undertake the Enquiry (‘to cause the enquiry’?)
LA

Health – SWYPFT
Health – CCG
Health – BHNFT
Give rationale for decision
If known at this stage is the adult at risk in agreement with the decision
Yes
No


If No please give Details
Provide Detailsof who will meet with individual to discuss the concern
Name;
Position;
Organisation;
Address:
Contact telephone / E Mail
Safeguarding Manager Decision
Enquiry Commenced
Signature / Date
Safeguarding Manager Decision
Does not meet 3 stage enquiry test - Log as a Safeguarding Concern
Signature / Date

Form amended 14.10.2015 - 1 -