Adult Safeguarding Referral Form

ADULT SAFEGUARDING REFERRAL FORM

Form fields marked with the M symbol are mandatory

These forms are being distributed in line with Southwark multi-agency Safeguarding Vulnerable Adults policy and procedure; the contents of which are confidential and can only be shared on a need to know basis, in the best interest of the Adult at Risk, or other Adults at Risk, and with their consent when it is appropriate to obtain it. They may need to be circulated to others as identified in the protection plan.

A. Please enter the following information about the adult at risk
Details of the adult at risk
Title:M / Forename:M / Surname:M / Date of Birth:(dd/mm/yyyy)M
Please selectMrMrsMsSirLadyDrProfOtherNot Known
Gender:M / Please selectFemaleMaleNot known / Religion:M / Please selectBaptistBuddhistChurch of EnglandHinduJewishMethodistMuslimRoman CatholicSikhOtherNoneNot KnownRefused to say
Client Group:M / Please selectOther Vulnerable AdultPhysical Disability / FrailtySensory ImpairmentLearning DisabilityMental HealthSubstance Misuse
Ethnicity:M / Please selectWhite: English/Welsh/Scottish/Northern IrishWhite: IrishWhite: Gypsy/Irish TravellerWhite: Any other White backgroundMixed: White and Black CaribbeanMixed: White and Black AfricanMixed: White and AsianMixed: Any other mixed backgroundAsian/Asian British: IndianAsian/Asian British: PakistaniAsian/Asian British: BangladeshiAsian/Asian British: ChineseAsian/Asian British: Any other Asian BackgroundBlack/Black British: AfricanBlack/Black British: CaribbeanBlack/Black British: Any other Black BackgroundOther ethnic group: ArabOther ethnic group: OtherNot stated / undeclared / refused to sayNot known
Sexual orientation:M / Please selectHetreosexualGay/LesbianBi-sexualPerson asked and does not know or is not surePerson asked but declined to provide a responseNot Stated
Person References / IdentifiersM
CareFirst ID: / EPJ ID: / NHS ID:
Health Conditions
An illness, disability or condition affecting the client - and diagnosed by a healthcare professional.
This does not need to be confirmed by the healthcare professional, and can be accepted in good faith from the person. Please tick all that apply.
Long Term Conditions - Physical / Long Term Conditions - Neurological
Chronic Obstructive Pulmonary Disease / Stroke
Cancer / Parkinson’s
Acquired Physical Injury / Motor Neurone Disease
HIV / AIDS / Acquired Brain Injury
Other Physical Health Condition / Other Neurological Health Condition
Learning, Developmental or Intellectual Disabilities / Sensory Impairment
Learning Disability / Visual Impairment
Autism / Hearing Impairment
Asperger’s / High Functioning Autism / Other Sensory Impairment
Other
Mental Heath
Dementia
Other Mental Health Condition
Address Information
Building Name / No:
Street:
Town/City:
County: / Post Code:
Address Type: / Please selectOwn HomeResidential Home - TemporaryResidential Home - PermanentNursing Home - TemporaryNursing Home - PermanentSheltered AccomodationAdult Placement SchemeHomelessParents/RelativeOther
Contact Information
Phone Number:
Mobile Number:
E-Mail Address:
GP Information
GP Name:
Practice Name:
Practice Address:
Capacity
Does the adult at risk have capacity in relation to the allegation of abuse?M / Please selectClient has capacityClient does not have capacityClient has fluctuating capacityClient to be assessedNot known
If the adult at risk has capacity please answer the following:
Does the adult at risk agree to the investigation? / Please selectYesNoNot applicable
Does the adult at risk agree to participate with the investigation? / Please selectYesNoNot applicable
If they did not agree to participate in the investigation, please describe why:
If the adult at risk does not have capacity or has fluctuating capacity please answer the following:
Please indicate here that a Mental Capacity Assessment has been completed
Mental Capacity Assessment Completion Date
Additional information
Was the adult at risk known to social / community services at the point of referral?M / Please selectYesNoNot Known
Is the adult at risk in receipt of social care services? M / Please selectYesNoNot Known
If the adult at risk is in receipt of services / support please answer the following questions;
Primary reason for support / services: / Please selectPhysical SupportSensory SupportSupport with Memory and CognitionLearning Disability SupportMental Health SupportSocial SupportNo Services Provided
How are the support / services being provided? / Please SelectPB - Council ManagedPB - Self ManagedPB - Mixed BudgetPB - Managed via Third PartyTraditional Care PlanNursing / Residential Package
Is the person known to other agencies? / Please selectYesNoNot known
If known to other agencies please state:
B. Please enter information regarding the Safeguarding Referral
Date referral received: (dd/mm/yyyy)M
Source of alert:M / Please selectDomicillary Care StaffResidential Care StaffDay Care StaffSocial Worker / Care ManagerSelf -Directed Care StaffSocial Care Staff - OtherPrimary/Community Health StaffSecondary Health StaffMental Health StaffSelf ReferralFamily MemberFriend / NeighbourCare Quality CommissionHousingEducation/Training/Workplace Establishment PoliceOther
Police CAD/MERLIN Reference (if appl.)
Details of the person who raised the alert (alerter):
Name
Role / Job
Relationship to the adult at risk
Organisation
Address
Contact Details
Details of the alert / allegation
Brief description of the alert, allegation, suspicion or concern.M
Date(s) / Time(s) of the alleged incident(s) (if known)
Location of alleged abuse / incidentM / Please selectOwn HomeCare Home - PermanentCare Home with Nursing - PermanentCare Home - TemporaryCare Home with Nursing - TemporaryAlleged Perpetrators HomeMental Health Inpatient SettingAcute HospitalCommunity HospitalOther Health settingSupported AccommodationDay Centre / ServicePublic PlaceEducation / Training / Workplace EstablishmentOtherNot Known
Alleged type of abuse
Please tick the alleged type of abuse – tick select all that apply;M
Discriminatory / Psychological / Emotional
Financial and Material / Neglect / Acts of Omission
Institutional / Sexual
Physical
Safeguarding alert history
Have there been alerts involving this adult at risk in the past? / Please selectYesNo
If there have been previous alerts please specify how many:
Please describe any previous history relevant to this latest referral:
Alleged Witnesses
Please provide details of all alleged witnesses below;
# / Title / Name / Role / Contact Details
1 / Please selectMrMrsMsSirLadyDrProfOtherNot Known
2 / Please selectMrMrsMsSirLadyDrProfOtherNot Known
3 / Please selectMrMrsMsSirLadyDrProfOtherNot Known
4 / Please selectMrMrsMsSirLadyDrProfOtherNot Known
C. Details of the alleged perpetrator
What is the alleged perpetrators relationship to the adult at risk?M / Please selectSocial Care - Domiciliary StaffSocial Care - Residential Care StaffSocial Care - Day Care StaffSocial Care - Social Worker/Care ManagerSocial Care - Self-Directed Care StaffSocial Care - Other StaffHealth - Primary/Community Health staffHealth - Secondary Health StaffHealth - Mental Health StaffSelf ReferralFamily MemberFriend/neighbourOther Service UserCare Quality CommissionHousingEducation/Training/Workplace EstablishmentPoliceUnknown / StrangerOther
Does the alleged perpetratorlive with the adult at risk?M / Please selectYesSometimes /OccasionallyNoNot known
Is alleged perpetrator a spouse, partner or family member?M / Please selectYesNoNot known
Is the alleged perpetrator a paid carer?M / Please selectYesNoNot known
Details of the alleged perpetrator
Please complete the details of the alleged perpetrator below.
If an allegation is made in respect of service provided where the perpetrator is an employee of a service provider / commissioned organisation please also complete the Organisation details.
Title: / Forename: / Surname: / Date of Birth: (dd/mm/yyyy)
Please selectMrMrsMsSirLadyDrProfOtherNot Known
Gender: / Please selectFemaleMale
Ethnicity: / Please selectWhite: English/Welsh/Scottish/Northern IrishWhite: IrishWhite: Gypsy/Irish TravellerWhite: Any other White backgroundMixed: White and Black CaribbeanMixed: White and Black AfricanMixed: White and AsianMixed: Any other mixed backgroundAsian/Asian British: IndianAsian/Asian British: PakistaniAsian/Asian British: BangladeshiAsian/Asian British: ChineseAsian/Asian British: Any other Asian BackgroundBlack/Black British: AfricanBlack/Black British: CaribbeanBlack/Black British: Any other Black BackgroundOther ethnic group: ArabOther ethnic group: OtherNot stated / undeclared / refused to sayNot known
Religion: / Please selectBaptistBuddhistChurch of EnglandHinduJewishMethodistMuslimRoman CatholicSikhNoneNot Known
Sexual orientation: / Please selectHetreosexualGayBisexualRefused to Say
Contact Details:
Is the alleged perpetrator known to social services? / Please selectYesNoNot Known
If known please complete the following information;
CareFirst ID: / EPJ ID: / NHS ID:
Is the alleged perpetrator currently in receipt of services? / Please selectYesNoNot Known
If yes, please specify:
Details of the Organisations thought to be causing harm / linked to the safeguarding concern.
Organisation Name:
Organisation Address:
Organisation Type: / Please selectAdvocacy / Support ServiceDomicillary Care ProviderExtra Care / Sheltered ProviderNursing Care ProviderResidential Care ProviderReablement / Intermediate Care ProviderSupported Living EstablishmentOther... please specify
If organisation type other please specify here:

LB Southwark – Adult Social Care – SA1 Safeguarding Referral Form (v3 Feb 2014) Page 1 of 8

D. Risk Assessment Tool
The risk assessment tool must be used on receipt of a referral to obtain an initial assessment of the severity of the allegation. This will also help with allocation of resources, immediate safety of person if required, level and timing of response and who to involve in the strategy discussion/meeting.

# / Risk Item / Likelihood
Score
(A) / Consequence Score
(B) / Total Risk
Score
(auto) / Risk
Indicator
(auto) / Is the risk modifiable? / Strategy to reduce the risk or the likely harm
1 / - select -Almost certainLikelyPossibleUnlikelyRare / - select -CatastrophicMajorModerateMinorInsignificant / Please selectYesNo
2 / - select -Almost certainLikelyPossibleUnlikelyRare / - select -CatastrophicMajorModerateMinorInsignificant / Please selectYesNo
3 / - select -Almost certainLikelyPossibleUnlikelyRare / - select -CatastrophicMajorModerateMinorInsignificant / Please selectYesNo
4 / - select -Almost certainLikelyPossibleUnlikelyRare / - select -CatastrophicMajorModerateMinorInsignificant / Please selectYesNo
5 / - select -Almost certainLikelyPossibleUnlikelyRare / - select -CatastrophicMajorModerateMinorInsignificant / Please selectYesNo
What are the views of the adult at risk?Do they now feel safe?

LB Southwark – Adult Social Care – SA1 Safeguarding Referral Form (v3 Feb 2014) Page 1 of 8

E. Safeguarding Action / Protection Plan
Action / Protection Plan
# / Item / Person/Agency Responsible / Date Due / Required
1
2
3
4
5
F. Safeguarding Referral Outcome
Outcome of the SA1 Adult Safeguarding Referral;
Please select an outcome for this referral below.
If Closure is planned please complete the SA3 Safeguarding Closure and Outcomes Form.
What was the agreed outcome of this referral?M / Please selectProgress to Strategy Discussion/Meeting (SA2)Progress to close Safeguarding Referral (SA3)
Date of DecisionM
Assigned Safeguarding Officers;
Where the decision has been taken to continue with the safeguarding procedure, please identify the workers assigned to the following safeguarding roles
Name of the Investigation Officer (IO):
Name of the Safeguarding Adults Manager (SAM):
Completing Worker’s Details;
Completing Worker’s Comments
Completing Worker’s NameM
Completing Worker’s RoleM
Completing Worker’s TeamM
Completing Worker’s Contact Details
Authorising Manager’s Details;
Authorising Manager’s Comments
Authorising Manager’s NameM
Authorisation DateM
Safeguarding Distribution List
Distribution Name / Team / When?
Head of Service & Service Manager / For ALL cases
Safeguarding Adults Co-ordinator

Telephone: 020 7525 1754
Fax: 020 7525 1711 / For ALL cases
Commissioning Team
/ For cases that involve a care home or a care package or other ‘paid for’ service.
Police

Telephone: 020 7232 6160
Fax: 020 7232 6276 / For cases where a crime may have been committed.
CQC

03000 - 616161 / For cases that involve a care home or a domiciliary care package
Corporate Anti-Fraud Team
Jenny Millgate, Safeguarding Adults Project Officer

Telephone: 020 7525 1163 / All cases where the financial abuse relates to a personal budget, direct payment, or financial needs assessment.
Client Affairs Team
Nilanti Peiris, Client Affairs Manager

Telephone:020 7525 3981 / For all cases which involve loss of money, where the service user is deemed to lack capacity to manage their affairs.
General Practitioner / For all cases where neglect, bullying or physical abuse is alleged & when the GP is very involved in the care of the Adult at Risk.

LB Southwark – Adult Social Care – SA1 Safeguarding Referral Form (v3 Feb 2014) Page 1 of 8

LB Southwark – Adult Social Care – SA1 Safeguarding Referral Form (v3 Feb 2014) Page 1 of 8