Adults at Risk Referral Form: Guidance Notes

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Adults at Risk Referral Form: Guidance Notes

Complete all sections of this form with as much information as you are able.

All sections within the form will expand automatically as you type – all forms must be typed.

DO NOT handwrite the form, there is insufficient room to add the information needed.

Please be aware: Forms with insufficient information will be returned to the referrer for further review and additional information to be added, this may result in untimely delay. If the form is returned due to insufficient information, your service director will be informed.

Consent and capacity

If you have no reason to doubt the capacity of an adult at risk to make a decision regarding whether or not they want an investigation, then you must ask them what they want to happen. Enabling and ensuring people are at the centre of decision making is a core element of clinical and social care practice.

Where you have reason to doubt the mental capacity of an adult at risk to make a decision regarding whether or not they want an investigation, you must use the framework set out by the Mental Capacity Act, 2005 and the associated code of practice. Failure to do this may result in criticism of your practice and may breach the human rights of the adult at risk. More information about the assessing capacity can be found by clicking here.

Information you may need to send with this referral

Ensure, whenever possible, that any mental capacity assessments, best interest decisions, risk assessments and protection plans/care plans and other necessary of relevant documents are e-mailed or faxed with this referral form.

Greater Manchester Police

Do not send the form to the police directly. The Community Screening Team will forward the form to the police if needed. If you or someone else is in danger or needs immediate help, dial 999.

If the person declines an investigation, you must still complete this form and send it to the Community Screening Team. This enables us to log all concerns and build up a picture of the level of abuse and harm happening in the Borough. Please note: There are circumstances when we will investigate, even if the adult at risk has said they refuse an investigation. We will do this when it is considered to be in the public interest. However, we will not inform the adult at risk of the need for a further investigation and we will try wherever possible to exclude them from the process.

Sending the form to the Community Screening Team

Because of the large number of agencies that use this form we are unable to provide cast iron guidance on how to send us this form. Please check your local information governance arrangements about faxing or e-mailing if you are unsure. DO NOT send this referral by Royal Mail – it should only be faxed or e-mailed using a secure system.

Feedback on your referral

You are entitled to feedback about your referral – if you have not received feedback within thirty days – please contact you organisation’s adult safeguarding lead or Trafford Council, NHS Trafford or Greater Manchester Police at Trafford. If you are an NHS employee, complete an incident form.

Information, advice, guidance and support in Trafford

We know this can be a challenging and concerning time: we want you to remember, you are not alone.

For information, advice guidance or support please contact:

Trafford Adult Safeguarding Team

Trafford Council – 0161 912 3375

For the Council Web pages click here

Greater Manchester Police,

Public Protection Division – 0161 856 7585

For GMP Web pages click here

Mr. Michel Le-Straad,

Designated Nurse for Vulnerable Adults, NHS Trafford – 0161 873 6084

For NHS web pages and links to other Councils click here

Ms. Julie Treadgold,

Named Nurse for Vulnerable Adults, Trafford Healthcare NHS Trust – 0161 748 4022

For NHS web pages and links to other Councils click here

Ms. Gilli Painter,

Named Professional for Safeguarding Adults, Greater Manchester West Mental Health NHS Foundation Trust

For NHS web pages and links to other Councils click here

Ms. Lesley Shaw,

Lead Nurse for Vulnerable Adults, University Hospital South Manchester NHS Foundation Trust - 0161 291 2382

For NHS web pages and links to other Councils click here

Ms. Julie Ryder,

Named Nurse for Vulnerable Adults, Central Manchester University Hospitals NHS Foundation Trust - 0161 276 1234

For NHS web pages and links to other Councils click here

Mrs. Claire Heneghan,

Named Nurse for Vulnerable Adults, Trafford NHS Provider Services - 0161 975 4716

For NHS web pages and links to other Councils click here

Mr. Phil Spilsted

Lead Nurse for Vulnerable Adults for Learning Disability Services in Trafford - 01244 397 643

For NHS web pages and links to other Councils click here

You can e-mail this completed form to the Community Screening Team or fax on 0161 912 5127
(check your local policy regarding fax and e-mail if unsure)
Out of Hours contact the Emergency Duty Team: 0161 912 2020 or email to:
This referral is for: CHOOSE ONLY ONE CATEGORY
Adult Safeguarding under inter-agency procedures / Yes No click here for a copy of the Trafford Procedures
Concern for welfare of a vulnerable adult / Yes No Information only? To signpost to other agencies?
TARGet Group (Trafford adults at risk group) / Yes No click here for link to TARGet
Domestic Abuse (complete this and the DASH) / Yes No Click here for the DASH risk assessment and complete it.
Risk Assessments: these must be updated and a protection plan written
Have you completed/updated a risk assessment? / Yes
No If no, please complete or update your risk assessment
Not Applicable as making a referral on secondary information
Has a protection plan been completed or the persons care plan updated to include a protection plan? / Yes
No If no, please complete a protection plan/update care plan
Not applicable as making a referral on secondary information
Information about the person making the referral:
Name:
Job title/Position: / Band if NHS:
Base/Office/Address / Telephone:
E-mail: / Mobile:
Date completed: / Time completed:
By completing this form I confirm that I have reasonable cause to suspect that a vulnerable adult may be at risk harm, neglect or abuse. The details of the adult and my reasons are contained within this form. If you require any further information, please contact me using the information above.
Information about the Adult at Risk:
Name of adult at risk: / NHS/SAP/PPI Number:
Date of Birth: / Sex: Female Male
Address: / Post Code:
Tel.no: / Mobile Number:
Ethnicity: / First Language:
Are there any communication difficulties? / Yes No If yes, tell us about them here:
Does the adult at risk require an interpreter? / Yes No If yes, tell us about this here:
Does the adult at risk require any other reasonable adjustment or support to communicate? / Yes No If yes, tell us about this here:
Does the adult at risk care for anyone else? / Yes No If yes, tell us about them here:
GP details, including address and contact number:
Tell us about any existing physical health difficulties, mental ill health or learning disability here:
Have any injuries been sustained by the adult at risk? / Yes No If yes, tell us about these in the next box
and complete a body map which you will find here
Details of injuries sustained:
Was the adult at risk under the influence of alcohol at the time of the incident? / Yes No Not known
If yes, provide as much additional information as possible here:
Was the adult at risk taking illicit drugs (such as benzodiazepines) at the time of the incident? / Yes No Illicit Not known
If yes, provide as much additional information as possible here:
Is this referral about prescription medications, including drugs errors? / Yes No Not known
If yes, provide as much additional information as possible here:
Does the adult at risk have an Advance Decision to refuse treatment in place? / Yes No Not known
If yes, where can a copy be found?
Complete this section re consent for adults for whom there are no concerns regarding mental capacity
Has the adult at risk given consent given to allow an investigation to commence? / Yes, adult at risk agrees to allow an investigation to commence
No, the adult at risk does not want an investigation to proceed. This referral is sent only for a log of the incident to be made. NB: You must advise the adult at risk, we may still investigate their allegation if it is in the wider public interest.
Unable to decide due to fluctuating capacity (complete section below)
Unable to ask the question at this stage because of safety concerns
Complete this section re consent for adults for whom there are concerns regarding mental capacity
Assessment of Mental Capacity
Click here for the Trafford Capacity Assessment Form
Please read attached guidance notes for further help
Please note well: If you have indicated on this form that you have completed a capacity assessment and made a best interest decision, these forms must be sent to the Community Screening Team with this referral. / I have not been able to assess capacity as it is not safe and/or appropriate to do so at this stage:
If you have ticked this box, do not answer the rest of the questions relating to capacity, further information will be asked of you at a later stage. Otherwise, please complete the rest of the section:
Do you believe the person lacks capacity to make the specific decision to agree to an investigation?
No (see box above for people where there are NO CONCERNS re capacity)
Yes (answer questions blow)
Capacity assessment completed Yes No (if no, consider question above)
Best Interest Decision made Yes No
Outcome: Investigate Do not investigate (only log incident)
Does the person require an Independent Mental Capacity Advocate (IMCA)?
Yes No (information about IMCA services can be found here)
Brief description of risks and information about the incident, issue or concern
Nature of vulnerability or risk to adult: e.g. Abuse by Neglect
Details of the incident, issue or concern:
If an incident, please tell us the date it occurred: / Time of incident:
Did you witness the incident or issue happen? / Yes No
Have you completed an incident form? / Yes No (if NHS staff complete one now!) No system in place
Did someone tell you the incident had happened? / Yes No
If so, what is their relationship to the adult at risk?
Please provide their contact details:

Information about the alleged perpetrator

Do you know who the alleged perpetrator is or is this referral about concerns raised within a service: / Yes (if yes, tell us about the alleged perpetrator below)
No
Concerns within a service, provide details here:
Name of the alleged perpetrator:
Age of the alleged perpetrator (if known): / Sex: Female Male
Address (if known): / Post Code:
Contact number (if known): / Mobile:
Is the alleged perpetrator known to have / Physical ill health/Long Term Conditions Mental ill Health
Learning Disability Learning Difficulty
Details of the alleged perpetrators mental/physical ill health:
Details of any Learning Difficulty or Learning Disability experienced by the alleged perpetrator:
Was the alleged perpetrator known or thought to be under the influence of alcohol at the time of the incident? / Yes No Not known
If yes, provide as much additional information as possible here:
Was the alleged perpetrator known or thought to be taking illicit or prescription drugs (such as benzodiazepines) at the time of the incident? / Yes No Not known
If yes, provide as much additional information as possible here:
Is the alleged perpetrator paid to care for the adult at risk? / Yes (if yes, tell us about their employer below)
No
Was the alleged perpetrator on duty at the time of the incident, issue, concern? / Yes
No
Name and address of their employer:
If known, tell us what their job role is (if known):
Is the alleged perpetrator’s employer aware that there are safeguarding concerns? / Yes No Not known
Is yes, please tell us who informed the employer and when, here:
Has the alleged perpetrators employer taken any immediate action against their employee? / Yes No Not known
Is yes, please provide as much information as possible here:
Is the perpetrator aware that a referral is being made? / Yes
No (if no, do not inform or contact the alleged perpetrator)
Deprivation of Liberty Safeguards
Is the adult at risk subject to an Urgent Authorisation under the Deprivation of Liberty Safeguards? / Yes No Unsure / If yes, when does this expire?
Is the adult at risk subject to a Standard Authorisation under the Deprivation of Liberty Safeguards? / Yes No Unsure / If yes, when does this expire?
Does the adult at risk require a review of their DoL? / Yes No Unsure
Tell us about any other people in household (include any children who visit the household)
If there are any Adult Safeguarding concerns about other adults, these will require a SEPARATE referral form. You can contact the Designated Nurse for Vulnerable Adults (0161 873 6084) or the Adult Safeguarding Team (0161 912 3375) during office hours. EDT can be contacted on 0161 912 2020 (Out of hours) for advice or support. A full list of contacts is included at the back of this document.
If there are concerns regarding Children or Young People contact the CYPS referrals and advice line: 0161 912 5125
Click here for the CYPS web pages
Person 1) Name:
DOB: / Sex:
Relationship to adult at risk: / Do they live in the household?
Address, if known / Post code
Person 2) Name
DOB: / Sex:
Relationship to adult at risk: / Do they live in the household?
Address, if known / Post code
Person 3) Name:
DOB: / Sex:
Relationship to adult at risk: / Do they live in the household?
Address, if known: / Post code
Person 4) Name:
DOB: / Sex:
Relationship to adult at risk: / Do they live in the household?
Address, if known / Post code
Details of other professionals or services involved in supporting the adult at risk
Community Nurse / Name: / Contact:
Midwife: / Name: / Contact:
Health Visitor: / Name: / Contact:
Specialist Nurse / Name: / Contact:
Type of Specialist Nurse (Tissue Viability, Cardiac Rehab, Continence etc)
Registered Social Worker / Review Officer / Name: / Contact:
Reablement Service / Name: / Contact:
Social care commissioned care agency / Name: / Contact:
Clinical Case Manager / Name: / Contact:
NHS commissioned care agency / Name: / Contact:
Community Matron / Name: / Contact:
Allied Health Professional / Name: / Contact:
Hospital Consultant / Name: / Contact:
Mental Health Consultant: / Name: / Contact:
Clinical Psychologist / Name: / Contact:
Learning Disability Consultant / Name: / Contact:
Community Mental Health Nurse: / Name: / Contact:
Community Learning Disability Nurse: / Name: / Contact:
Other (Please describe here): / Name: / Contact:
Please record below safety issues or risks for staff/professionals visiting
Tell us about issues/risks here:
Please provide any other information you believe is relevant

For Adult Social Care use ONLY

Feedback to referrer

Community Screening Team

Date and time referral received:

/

Date: Time:

Screened by:

/

Has the Alerter provided sufficient information on the referral for it to be processed and action taken?

/

Yes No ,

If no return the form to the Alerter and inform their Service Director.

Person informed:

Date informed:

Sent to GMP Yes No

/

If yes, Date: Time:

Feedback to referrer after screening: / Date: / By whom:
Sent to: (Name of Social Work or Clinical Team) / Date:

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