Knowsley Safeguarding Adults Alert Form

This form may be completed by any agency: please send it in with as much information as is available,

it does not matter if you are unable to complete all sections.

Double click on the grey boxes to select from drop-down lists.

1 Full Name of Adult at Risk / 2 DOB / 2a SWIFT No: (If known)
3 Title / MrMrsMissMasterMs / 4 Gender / FemaleMale / 4a Ethnic Origin / White EnglishWhite WelshWhite BritishWhite ScottishWhite Northern IrishWhite Gypsy or Irish TravellerWhite Any other White backgroundMultiple ethnic group White and Black CaribbeanMultiple ethinc group White and Black AfricanMultiple ethnic group White and AsianMultiple ethnic group Any other mixedAsian/Asian British - IndianAsian/Asian British - PakistaniAsian/Asian British - BangladeshiAsian/Asian British - ChineseAsian/Asian British - Any other Asian backgroundBlack/African/Caribbean/Black British - AfricanBlack/African/Caribbean/Black British - CaribbeanBlack/African/Caribbean/Black British - Any otherOther ethnic group - ArabOther ethnic group - Any other ethnic groupNot statedUndeclared/Not known
5 If an incident has occurred please give date and time (approximate), if known: / Date Time
6 Is the person aware of this referral? / NoYes
7 Adult at risk – nature of care and support need(Please select from list) / Physical Support Access and MobilityPhysical Support Personal Care SupportSensory VisualSensory HearingSensory DualSupport with Memory and CognitionLearning Disability SupportMental Health SupportSocial Support Substance MisuseSocial Support Asylum SeekerSocial Support Social Isolation/OtherNot KnownSocial Support Carer
8 Has the person consented to this referral? If consent is not given, you must report anyway / No - consent not sought as would cause delayYesNo - lacks capacity to consentNo - consent refusedDon't know
9 Has the personconsented to this information being shared? / No - consent not sought as would cause delayYesNo - lacks capacity to consentNo - consent refusedDon't know
10 Making Safeguarding Personal. What does the person want to happen?(If known, please give details of the person’s wishes)
11 Does the person need support with communication? (If so please specify)
12 Address of Adult at Risk
13 Type of accommodation e.g. own home, residential/nursing/supported living etc. / 13a If living in a care service please state funding authority or whether self-funded / YesNoDon't Know / 13b If living in a care service please state name of Unit
13c If in a care service please state if adult is temporary or long term resident
14 Telephone Number
15 Other Agencies involved
16 Other people involved in the adult’s care e.g. relatives
Details of Alerter – (this is either yourself or the person who alerted you to concerns about this adult.
17a Name
17b Role/Relationship
(if other please specify) / Hospital/A&EPrimary Care NHS (eg GP, Community based NHS prof)HousingResidential Care Domiciliary CareDay CareSocial WorkerKMBC Other DeptKMBC - Out Of HoursLegal - PoliceLegal - Probationary/SolicitorMental Health StaffSelfSelf Directed CareFamilyFriend/NeighbourOther Service UserOLA - Other Local AuthorityOther Individual (Councillor/MP/AdovocateOther
17c Organisation Name / 17d Address
17e Telephone Number / 17f E-mail address
Details of Incident/Concern
18 Location of the Incident/risk / In the community(excluding comm'y services)In a community serviceCare Home-NursingCare Home-ResidentialOwn HomeHospital - Mental HealthHospital - AcuteHospital - CommunityOther
19 What type(s) of abuse do you think has occurred/may occur? / Main Category / PhysicalPsychologicalNeglectOrganisationalSexualDomesticSelf NeglectFinancialDiscriminatoryModern SlaveryCHANNEL (Extremist Behaviour)Sexual Exploitation
Sub Category (If there is more than one type of abuse please select the sub-category) / PhysicalPsychologicalNeglectOrganisationalSexualDomesticSelf NeglectFinancialDiscriminatoryModern SlaveryCHANNEL (Extremist Behaviour)Sexual Exploitation / PhysicalPsychologicalNeglectOrganisationalSexualDomesticSelf NeglectFinancialDiscriminatoryModern SlaveryCHANNEL (Extremist Behaviour)Sexual Exploitation
PhysicalPsychologicalNeglectOrganisationalSexualDomesticSelf NeglectFinancialDiscriminatoryModern SlaveryCHANNEL (Extremist Behaviour)Sexual Exploitation / PhysicalPsychologicalNeglectOrganisationalSexualDomesticSelf NeglectFinancialDiscriminatoryModern SlaveryCHANNEL (Extremist Behaviour)Sexual Exploitation
20 Any witnesses? Please state name, role and contact details if available / Name:
Role:
Contact Details:
21 Description of alleged incident/risk (have you included date and time at the top of this form?) / Description:
PLEASE ATTACH A WRITTEN RECORD OF WHAT YOU SAW, HEARD, OR WERE TOLD TO THIS FORM
IF APPLICABLE PLEASE ATTACH A BODY MAP
Source of Risk
22 Who is the Adult at risk from? Name of person or Organisation alleged to have caused harm
23 Do you have any details – address, DOB, approx age
24 Is the person alleged to pose the risk also an adult with care and support needs? If so, why?(Please select from list) / 24aTheir relationship to the adult at risk?(Please select from list) / Known - Individual known but not relatedKnown - Relative/family carerKnown - Primary Health CareKnown - Secondary Health CareKnown - Community Health CareKnown - PoliceKnown - RegulatorKnown - Other public sectorKnown - Other private sectorKnown - Other voluntaryUnknown - Individual/StrangerUnknown - Primary Health CareUnknown - Secondary Health CareUnknown - Community Health CareUnknown - PoliceUnknown - RegulatorUnknown - Other public sectorUnknown - Other private sectorUnknown - Other voluntaryService Provider - Public sectorService Provider - Private sectorService Provider - Voluntary sectorKnown-Social Care staff-care managem't & assessm'tUnknown-care managem't & assm't
25 Details of person completing this form / 25a Name / 25b Role
26 Telephone Number
27 Organisation and Address
28Name of Person completing form / 29 Date

The information contained in this document is confidential and is to be used solely for the purpose of safeguarding an adult at risk. If you are not the intended recipient you should not copy or use any part of it or disclose its contents to any person.

This Form should be completed electronically and emailed securelyfrom a SECURE email address.

If sending from a SECURE government account i.e. any account with the following suffixes:

@gcsx.gov.uk @gsisup.co.uk

@gsi.gov.uk @pnn.gov.uk

@

@gse.gov.uk @cjsm.net

@scn.gov.uk @nhs.net

You can email SECURELY to:

If you do not have aSECURE government account then you must send via Egress Switch SECURE email to:

Knowsley.AccessTeam@knowsley. gov.uk

Out of hours Phone Contact

Tel No: 0151 443 2600

You can use this number to contact Knowsley Adult and Children's Social Care out of hours team to help with emergencies between 5pm and 9am every weekday, all weekends and public holidays. Or dial 999 if someone needs police help in an emergency, electronic forms submitted will NOT be monitored during this period.

Should you require any advice or guidance about the Safeguarding Adults Policy & Procedures please contact the Safeguarding Adults Unit on 0151 443 4888

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