Safeguarding Adults Reporting for Professionals in North East Lincolnshire

- Step 1 of 7

Please note: This form is only for use between 08:00 and 17:00, Monday to Friday, excluding bank holidays.
Outside these hours, please call 01472 256256 (Option 2).

PLEASE NOTE: THIS FORM IS FOR PROFESSIONALS ONLY

If a crime is in progress, emergency response is required. You should contact the emergency service by dialling 999.

For non-emergency crime please contact the police by calling 101.

If you are a professional raising a safeguarding concern about an adult, please ensure you have considered the relevant pathways below before submitting a referral.

Before Making a Safeguarding Contact

Please check if any of the following pathways are more appropriate for your concern:

Support with daily living: If you require information and advice regarding care and support, please contact Focus Independent Adult Social Care via Single Point of Access on 01472 256256 option 2.
Unpaid carers: For information and advice see Focus Adult Social Care Website.
Children's Safeguarding: If you believe that a child may be a victim of neglect, abuse or cruelty call Children's safeguarding via Integrated Front Door on 01472 326292.

When considering an adult safeguarding concern under the Care Act 2014, please ensure the following key criteria are met:

Has needs for Care & Support (whether or not the Local Authority is meeting those needs)
Is experiencing, or at risk of, Abuse and Neglect
As a result of those care needs is unable to protect themselves from either the risk of, or the experience of Abuse and Neglect.

Referral Best Practice:

Where possible, discuss your concerns with the adult involved and obtain their consent to refer.
If consent cannot be given or it is unsafe to obtain it, proceed with the referral in line with safeguarding policies.

If you have any queries completing this form please contact Single Point of Access on 01472 256256 option 2.

Please Note: Professionals Cannot Remain Anonymous

Person Raising the Concern

Name (Person Raising Concern) *

First

Last

Relationship to Adult at Risk *

Job Title *

Email Address *

Telephone Number *

Organisation Address *

Adult at Risk Details

Name (Adult at Risk 1) *

First

Last

Date of Birth (Adult at Risk 1) *

Gender (Adult at Risk 1) *

If 'Other' please self identify below *

Sexual Orientation (Adult at Risk 1) *

If 'Other' please self identify below *

Ethnicity (Adult at Risk 1) *

If 'Other' please identify *

Religion (Adult at Risk 1) *

If 'Other Religion' selected please give further details *

Telephone Number (Adult at Risk 1) *

Can the Adult at Risk be contacted via the telephone number provided? (Adult at Risk 1) *

If 'No' selected please give details of how to safely contact the adult at risk *

NHS Number of Adult at Risk (Adult at Risk 1) *

Address of Adult at Risk (Adult at Risk 1) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Can the Adult at Risk be contacted be contacted at this address? (Adult at Risk 1) *

If 'No' please give details of how to gain access to the person and who can be contacted if there are difficulties. *

Is the Adult at Risk known to Mental Health Services (Adult at Risk 1) *

Primary communication needs of the adult at risk due to sensory or other impairments (including dementia), including any interpreter or communication requirements (Adult at Risk 1) *

What are the primary care needs of the Adult at Risk? eg. disability or illness *

Funding Authority *

If you selected 'Other' please give details of the funding authority *

Is the Adult at Risk aware of the alleged safeguarding concern raised on their behalf? *

Has the Adult at Risk consented to the safeguarding concern being raised? *

If the Adult at Risk has not consented, on what grounds was the decision made? *

If the Adult at risk hasn't consented, is reporting the safeguarding concern in the public interest? *

Is there evidence to suggest that there is a serious risk of harm to the Adult at Risk which would prevent them from consenting to the safeguarding concern being raised? *

Yes
No
Unknown

If 'Yes' please provide more details *

Is there any information which you have that suggests that the Adult at Risk cannot consent to the safeguarding concern because of any of the following: Undue influence, coercion and/or control of a third party? *

Yes
No
Unknown

If 'Yes' please provide more details *

Has the person's mental capacity to consent to the safeguarding concern been questioned by you or anyone else? If so, provide details (please refer to MCA Code of Practice 4.35). *

Yes
No
Unknown

If 'Yes' please provide more details *

Has the person's capacity to make the decision been assessed? *

Yes
No
Unknown

If 'Yes' give details of who who performed the assessment and what the outcome was. *

Advocate

Is there an appropriate person identified who is able to advocate on behalf of adult at risk? *

If 'Yes' please give details of the appropriate person and how to contact them *

Does the Adult at Risk require a referral to Advocacy services? *

What are the desired outcomes of the Adult at Risk? (What does the Adult at Risk wish to happen as a result of the safeguarding concern?) *

If the desired outcomes are unknown, please state.

If we need to visit, have you identified any risks or concerns that we should be aware of? *

If 'Yes' please give details *

Is there a second adult at risk? *

Adult at Risk Details (2)

Name (Adult at Risk 2) *

First

Last

Date of Birth (Adult at Risk 2) *

Gender (Adult at Risk 2) *

If 'Other' please self identify below (Adult at Risk 2) *

Sexual Orientation (Adult at Risk 2) *

If 'Other' please self identify below (Adult at Risk 2)

of to harm

Ethnicity (Adult at Risk 2) *

If 'Other' please identify (Adult at Risk 2) *

Religion (Adult at Risk 2) *

If 'Other Religion' selected please give further details (Adult at Risk 2) *

Telephone Number (Adult at Risk 2) *

Can the Adult at Risk be contacted via the telephone number provided? (Adult at Risk 2) *

If 'No' please give details of how to gain access to the person and who can be contacted if there are difficulties. (Adult at Risk 2) *

NHS Number of Adult at Risk (Adult at Risk 2) *

Address of Adult at Risk 2 *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Can the Adult at Risk be contacted be contacted at this address? (Adult at Risk 2) *

If 'No' please give details of how to gain access to the person and who can be contacted if there are difficulties. (Adult at Risk 2) *

Is the Adult at Risk known to Mental Health Services (Adult at Risk 2) *

Primary communication needs of the adult at risk due to sensory or other impairments (including dementia), including any interpreter or communication requirements (Adult at Risk 2) *

Funding Authority (Adult at Risk 2) *

If you selected 'Other' please give details of the funding authority (Adult at Risk 2) *

Is the Adult at Risk aware of the alleged safeguarding concern raised on their behalf? (Adult at Risk 2) *

Has the Adult at Risk consented to the safeguarding concern being raised? (Adult at Risk 2) *

If the Adult at Risk has not consented, on what grounds was the decision made? (Adult at Risk 2) *

If the Adult at risk hasn't consented, is reporting the safeguarding concern in the public interest? (Adult at Risk 2) *

Is there evidence to suggest that there is a serious risk of harm to the Adult at Risk which would prevent them from consenting to the safeguarding concern being raised? (Adult at Risk 2) *

Yes
No
Unknown

If 'Yes' please provide more details (Adult at Risk 2) *

Yes
No
Unknown

If ' Yes' please provide more information (Adult at Risk 2) *

Has the person's mental capacity to consent to the safeguarding concern been questioned by you or anyone else? If so, provide details (please refer to MCA Code of Practice 4.35). (Adult at Risk 2) *

Yes
No
Unknown

If 'Yes' please provide more details (Adult at Risk 2) *

Has the person's capacity to make the decision been assessed? (Adult at Risk 2) *

Yes
No
Unknown

If 'Yes' give details of who who performed the assessment and what the outcome was. (Adult at Risk 2) *

Advocate

Is there an appropriate person identified who is able to advocate on behalf of adult at risk? (Adult at Risk 2) *

If 'Yes' please give details of the appropriate person and how to contact them (Adult at Risk 2) *

Does the Adult at Risk require a referral to Advocacy services? (Adult at Risk 2) *

What are the desired outcomes of the Adult at Risk? (What does the Adult at Risk wish to happen as a result of the safeguarding concern?) (Adult at Risk 2) *

If the desired outcomes are unknown, please state.

If we need to visit, have you identified any risks or concerns that we should be aware of? (Adult at Risk 2) *

If 'Yes' please give details (Adult at Risk 2) *

Details of Person Alleged to Have Caused Harm (Person 1)

Name (Person Alleged to Have Caused Harm 1) *

First

Last

Date of Birth *

Gender *

If 'Other' please self identify below *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Ethnicity *

If 'Other' please state *

Relationship to Adult at Risk *

Are they living with the adult at risk? *

Are they the main carer of the adult at risk? *

Are they a member of staff, paid carer, or volunteer? *

Yes
No
Unknown

If 'Yes', what is their job role? *

Are they employed via a personal budget? *

Yes
No
Unknown

Which organisation are they employed by? *

Is the person alleged to have caused harm also a vulnerable adult? *

Yes
No
Unknown

If 'Yes' please give details *

Are they aware of the concern? *

Yes
No
Unknown

If 'Yes' please give details *

Are there other people at risk from the person causing harm? *

Yes
No
Unknown

If 'Yes' please give details of risk to others *

Categories of alleged abuse *

Is there a second person alleged to have caused harm?

Details of Person Alleged to Have Caused Harm (Person 2)

Name (Person Alleged to Have Caused Harm 2) *

First

Last

Date of Birth (Person 2) *

Gender (Person 2) *

If 'Other' please self identify below (Person 2) *

Address (2) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Ethnicity (2) *

If 'Other' please state (2) *

Relationship to Adult at Risk (Person 2) *

Are they the main carer of the adult at risk? (Person 2) *

Are they living with the adult at risk? (Person 2) *

Are they a member of staff, paid carer, or volunteer? (Person 2) *

Yes
No
Unknown

If 'Yes', what is their job role? (Person 2) *

Is the person alleged to have caused harm also a vulnerable adult? (Person 2) *

Yes
No
Unknown

If 'Yes' please give details (Person 2) *

Are they aware of the concern? (Person 2) *

Yes
No
Unknown

If 'Yes' please give details (Person 2) *

Are there other people at risk from the person causing harm? (Person 2) *

Yes
No
Unknown

If 'Yes' please give details of risk to others (Person 2) *

Is there a third person alleged to have caused harm? *

Details of Person Alleged to Have Caused Harm (Person 3)

Name (Person Alleged to Have Caused Harm 3) *

First

Last

Date of Birth (Person 3) *

Gender (Person 3) *

If 'Other' please self identify below (Person 3) *

Address (Person 3) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Ethnicity (Person 3) *

If 'Other' please state (Person 3) *

Relationship to Adult at Risk (Person 3) *

Are they the main carer of the adult at risk? (Person 3) *

Are they living with the adult at risk? (Person 3) *

Are they a member of staff, paid carer, or volunteer? (Person 3) *

Yes
No
Unknown

If 'Yes', what is their job role? (Person 3) *

Is the person alleged to have caused harm also a vulnerable adult? (Person 3) *

Yes
No
Unknown

If 'Yes' please give details (Person 3) *

Are they aware of the concern? (Person 3) *

Yes
No
Unknown

If 'Yes' please give details (Person 3) *

Are there other people at risk from the person causing harm? (Person 3) *

Yes
No
Unknown

If 'Yes' please give details of risk to others (Person 3) *

Is there a fourth person alleged to have caused harm? *

Details of Person Alleged to Have Caused Harm (Person 4)

Name (Person 4) *

First

Last

Date of Birth (Person 4) *

Gender (Person 4) *

If 'Other' please self identify below (Person 4) *

Address (Person 4) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Ethnicity (Person 4) *

If 'Other' please state (Person 4) *

Relationship to Adult at Risk (Person 4) *

Are they the main carer of the adult at risk? (Person 4) *

Are they living with the adult at risk? (Person 4) *

Are they a member of staff, paid carer, or volunteer? (Person 4) *

Yes
No
Unknown

If 'Yes', what is their job role? (Person 4) *

Is the person alleged to have caused harm also a vulnerable adult? (Person 4) *

Yes
No
Unknown

If 'Yes' please give details (Person 4) *

Are they aware of the concern? (Person 4) *

Yes
No
Unknown

If 'Yes' please give details (Person 4) *

Are there other people at risk from the person causing harm? (Person 4) *

Yes
No
Unknown

If 'Yes' please give details of risk to others (Person 4) *

Details of Abuse

Details of the alleged abuse, neglect and/or acts of omission: *

For Example: What impact is this having on the adult at risk? What is the Adult at Risk saying about the Abuse? What would they like to happen as a result of the safeguarding concern? How and when did the concern come to light? Were there any witnesses to the alleged abuse? Are there any children under the age of 18 at risk of harm as a result of the alleged safeguarding concerns?

Alleged Abuse Location *

Date of Alleged Abuse *

Have the police been informed? *

If 'Yes' please provide the Log Number *

Immediate Safety Plan

What are the details of any immediate plans that have been put in place to safeguard the adult at risk from further harm? *

For Example: What is the crime number if a report has been made to the police? Were emergency services contacted? Has this concern been reported to the CQC or another regulatory body, if so give details of the reference numbers?

Date of action/s taken *

Please note: This form is only for use between 08:00 and 17:00, Monday to Friday, excluding bank holidays. Outside these hours, please call 01472 256256 (Option 2).

*PLEASE NOTE: THIS FORM IS FOR PROFESSIONALS ONLY*

If a crime is in progress, emergency response is required. You should contact the emergency service by dialling 999.

For non-emergency crime please contact the police by calling 101.

Please Note: Professionals Cannot Remain Anonymous

Person Raising the Concern

Adult at Risk Details

Advocate

Adult at Risk Details (2)

Advocate

Details of Person Alleged to Have Caused Harm (Person 1)

Details of Person Alleged to Have Caused Harm (Person 2)

Details of Person Alleged to Have Caused Harm (Person 3)

Details of Person Alleged to Have Caused Harm (Person 4)

Details of Abuse

Immediate Safety Plan

Please note: This form is only for use between 08:00 and 17:00, Monday to Friday, excluding bank holidays.
Outside these hours, please call 01472 256256 (Option 2).

PLEASE NOTE: THIS FORM IS FOR PROFESSIONALS ONLY