Safeguarding Concern
Safeguarding Concern
.
This form should be completed to record a formal Safeguarding concern. Where a criminal
act may have been committed against an adult at risk. The Police must also be notified.
.
This form should be completed to report any incident or suspicion or concern of an adult at
risk of harm:
.
Where the adult at risk is already known to a social worker:
Allocated Social Worker or Team Manager.
.
Where the adult at risk is not already known to a social worker:
Waltham Forest Direct – Tel: 020 8496 3000, Email: Safeguarding.Adults@walthamforest.gov.uk
.
If outside normal office hours, or at the weekend or a Bank Holiday:
To SOCIAL SERVICES EMERGENCY DUTY TEAM
Tel: 020 8496 3000
.
If you are unable to complete the alert form, please telephone the Safeguarding Adults Team who
will be pleased to complete the form on your behalf.
Frameworki ID
RiO ID
Title
Gender
Forenames
Family Name
Date of Birth
Age
Permanent Address
Postcode
Home Telephone
Mobile Telephone
Is the Adult at Risk already in receipt of Social Care Services? (Please tick as appropriate)
Yes
SA Concern
No
Section 1 - AGE GROUP
18 - 64
85 - 94
65 - 74
95+
75 - 84
Unknown
Section 1 - NORMAL RESIDENCE
Own home
Residential Home
with Nursing
Supported Housing
Residential Care Home
Sheltered Housing
If 'Other', please specify
Temporary
Accommodation
Hospital
Other
Shared Lives Scheme
Rough Sleeper
No Fixed Abode
Section 1 - PRIMARY NEED OF THE ADULT AT RISK OR SERVICE USER GROUP - IF KNOWN
Physical Disability
Mental Health Under 65
Carer
If 'Other', please specify
Sensory Impairment
Mental Health Over 65
Dementia
Learning Disability
Substance Misuse
Other At Risk Group
Section 1 - Does the Adult at Risk have full mental capacity in relation to the safeguarding concern?
Yes
No
Unknown
Section 1 - Is the Adult at Risk aware of a safeguarding concern having been raised?
Yes ‘Aware’
If ‘No' not aware, please state why?
No ‘Not aware’
Section 1 - FUNDING ARRANGEMENTS
Service commissioned and funded by
LBWF
Self funded service
Service commissioned and funded by
another local authority
Service funded by Waltham Forest NHS
body
No service provided
Service funded by non- Waltham Forest
NHS body
If service funded by another local authority or health body, please specify
SA Concern
Section 1 - Does the adult at risk have any previous history of safeguarding alerts within the last financial
year (1st April to 31st March)?
Yes
No
If 'Yes' please state the date and the type of harm.
Unknown
Section 1 - THE ADULT AT RISK ETHNICITY
White
White British
White Irish
Traveller of
Irish heritage
Roma or Gypsy
Mixed
White & Black
Caribbean
White & Black
African
White & Asian
Any other mixed background
Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background
Black or Black British
Caribbean
African
Any other Black background
Eastern European
Any other ethnic group
Other Ethnic Groups
Chinese
Not stated
Refused
Any other white
background
Information not obtained
Section 1 - THE ADULT AT RISK RELIGION
Buddhist
Muslim
If “Other”, please specify
Christian
Sikh
Hindu
None
COMMUNICATION
Preferred Language - Communication Method
Interpreter required
THE ADULT AT RISK SEXUAL ORIENTATION
SA Concern
Signer required
Jewish
Other
Heterosexual
Transgender
Lesbian
Preferred not to say
Gay
Not known
Bisexual
Other
The Allegation
Section 2 - Brief outline of alleged harm
Date of incident - If known
Section 2 - Date incident reported
Section 2 - INCIDENT REPORTED BY
Social Care Staff (any sector)
Domiciliary care staff
Residential or nursing home
staff
Self-Directed Care Personal
Assistant
Day care staff
Health Staff
Primary or community health
staff
Secondary (hospital) health
staff
Mental Health staff
Other sources of referral
Self referral
Family member
Friend or neighbour
Care Quality Commission
(CQC)
Housing Service
Police
Social Worker or Care
Manager
If “Other”, please specify
Other service user
Education, training or
workplace
Voluntary Organisation
Other
Other
If “Other” or "Voluntary Organisation", please specify
Section 2 - WHERE DID THE ALLEGED INCIDENT TAKE PLACE
Own home
Residential care home
(Permanent)
Residential home with nursing
Residential home with nursing
(Permanent)
(Temporary)
Mental Health Inpatient
Acute Hospital
setting
SA Concern
Residential care home
(Temporary)
Home of the alleged person
who caused the harm
Community Hospital
Other health setting
Supported accommodation
Day Centre / Service
Public place
Education, training or
workplace
Not known
Other
If “Public Place” or “Other”, please give details
TYPE OF HARM INCLUSIVE OF CARE ACT ADDITIONAL CATEGORIES (tick all that apply)
Physical Harm
Sexual Harm
Neglect Harm
Financial Harm
Discriminatory Harm
Institutional Harm
Domestic
Violence/Harm
Modern Slavery
Sexual Exploitation
Self-Neglect
Psychological or
emotional Harm
DEFINITIONS OF CARE ACT ADDITIONAL CATEGORIES OF HARM:
Types of Harm
Definitions of Harm
Domestic Harm
An incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or
abuse by someone who is or has been an intimate partner or family member regardless of
gender or sexuality. It can include: psychological, physical, sexual, financial, emotional abuse;
‘honour’ based violence; Female Genital Mutilation; forced marriage.
Sexual Exploitation
Involves exploitative situations and relationships where people receive 'something' (e.g.
accommodation, alcohol, affection, money) as a result of them performing, or others
performing on them, sexual activities.
Self-Neglect
Covers a wide range of behaviour; neglecting to care for one’s personal hygiene, health or
surroundings and includes behaviour such as hoarding.
Modern Slavery
Encompasses slavery, human trafficking, forced labour and domestic servitude. Traffickers and
slave masters use whatever means they have at their disposal to coerce, deceive and force
individuals into a life of abuse, servitude and inhumane treatment.
THE PERSON OR INSTITUTION SUSPECTED OF CAUSING THE HARM - IF KNOWN
Name and Initials
Gender
Date of birth
Approximate age (if dob not known)
Address if known
Employer
If the allegation is of institutional harm, please name the provider:
SA Concern
Section 2 - THE ALLEGED PERSON'S RELATIONSHIP TO ADULT AT RISK IS:
Partner
Other family member
Health care worker
Volunteer / Befriender
Domiciliary Care staff
Residential Care staff
Day Care Staff
Social Worker or Care
Manager
Other professional (please
specify)
Stranger
Self-Direct Care Staff
Social Care Worker: other
(please specify)
Neighbour or friend
Other Vulnerable Adult
Not known
Other
If "Social Care Worker: other", or "Other professional" or “Other”, please specify
Section 2 - Was the person alleged to have caused the harm living with the adult at risk at the time the
incident occurred?
No
Yes
Section 2 - Is the person alleged to have caused the harm still living with the adult at risk?
Yes
No
Section 2 - Is the person alleged to have caused the harm the main family carer?
Yes
No
Section 2 - Was the alleged person causing the harm working with the adult at risk?
Yes
No
Section 2 - Is the alleged person causing the harm still working with the adult at risk?
Yes
No
RISK ASSESSMENT AND INITIAL PROTECTION PLAN
Risk/Vulnerability
Action to Address
Person/Agency
responsibile
Time Scale
Section 2 - Is the person who allegedly caused the harm aware of the safeguarding concern?
No ‘not aware’
Yes ‘is aware’
If ‘No' not aware please state why?
SA Concern
Section 2 - Is the adult at risk agreeable to sharing information?
'Yes’ is agreeable to share information.
'Yes’ with limitations.
‘No’ not agreeable to sharing information.
Unable to consent.
If ‘Yes' with limitations please specify the limitations?
HAS MEDICAL ATTENTION BEEN GIVEN AS A RESULT OF THIS INCIDENT?
No
Yes
To whom reported
Section 2 - HAVE THE POLICE BEEN INFORMED?
No
Yes
Crime Reference Number or CAD Number (if known)
Police Officers Name or Number
Date
Police Action (if known)
DETAILS OF PERSON COMPLETING THIS FORM
Section 2 - Name
Section 2 - Job Title
Section 2 - Team
Section 2 - Date completed
Section 2 - Telephone Number
Section 2 - E-mail address
In line with the Pan London Policy & Procedure, all Safeguarding Adults referrals (SA1) will progress
to the Strategy meeting / discussion.
The Safeguarding Strategy meeting / discussion must be undertaken within 5 working days from the
date the allegation is disclosed / reported.
SA Concern
London Borough Waltham Forest
Alert Closure page for issues that are deemed not to be Safeguarding.
Adult at Risk Name: …………………………………
ISIS / RIO No: …………………………….
The following section is to be completed by the appropriate Manager in LBWF or NELFT who
has responsibility to determine whether the Alert is to be addressed in accordance with Adult
Safeguarding Procedures.
Please complete the following information:-
1. Is the Alert a Safeguarding issue?
SA Concern
2. If the Alert is not a Safeguarding issue,
it will be dealt with as follows:-
Yes
If ‘YES’ please complete
SA1 Referral Form.
a) Care management referral
b) No action to be taken
c) Other (Please state action)
No
Why is this not considered to be a safeguarding issue?
Details of the manager for the determination of this safeguarding alert.
3. MANAGERS
NAME
JOB TITLE
ORGANISATION/CONTACT
DETAILS
DATE
When the Manager has completed this section, this form must be uploaded onto iSIS and
a copy sent to the Safeguarding Adults Team (safeguarding.adults@walthamforest.gov.uk)
SA Concern