London Borough of Newham SA1 - Safeguarding Adults Alert Form - Confidential
Please complete all Questions or note as “not applicable”
Form Start DateDetails of Adult at Risk
Family name / Given name
Date of birth (dd/mm/yyyy) / Social care ID
Main address
BACKGROUND INFORMATION
NHS Number
Is the Adult at risk a new or existing Customer?
Has this Adult at risk been placed in Newham by another borough?
Enter Adult at Risk’s Current address if this is different to the Main address above
Can this address be shared outside of Adult Services?
Type of Accommodation
Gender(mandatory) / Preferred language(mandatory)
Religion(mandatory)
Ethnicity(mandatory)
Marital Status(mandatory) / Does the person need an interpreter(mandatory)
Client Group(mandatory) / Asylum Seekers/RefugeesDementiaDual Sensoy LossFrailty/Temporary IllnessHearing ImpairmentLearning DisabilityMental HealthMental Health Support Needs - AlcoholMental Health SUpport Needs - DrugsMental Health Support Needs - Substance MisusePhysical DisabilitySubstance Misuse - AlcoholSubstance Misuse - DrugsSubstance Misuse - Drugs & AlcoholSubstance Misuse-Drugs with MH NeedsSustance Misuse-Alcohol with MH NeedsSubstance Misuse -Drugs & Alc with MH NeedsVisual ImpairmentWelfare Benefits
GP and Next of Kin Details
Next of kin / GP
Relationship / Practice
Tel no / Tel no
Address
Email address / Email address
Care Support / Plan Details
What type of care/support plan does the Adult at Risk have? (mandatory) / Commissioned Care PlanCommissioned Care Plan - Other LADirect PaymentHealth FundedNo Care PlanSelf Directed SupportSelf Funded
Who provides the care plan?(mandatory)
Is the alert against the provider?(mandatory)
Details of Alleged Incident
Date of Alert(mandatory)
Date of Alleged Incident(mandatory)
Time of Alleged Incident
Location of Alleged Incident (mandatory)
Please provide details of where this happened e.g. name of Home
Acute HospitalAlleged Perpretrators HomeCare Home - PermanentCare Home - TemporaryCare Home With Nursing - PermanentCare Home With Nursing - TemporaryCommunity HospitalDay Centre/ServiceEducation/Training/WorkplaceEstablishmentMental Health Inpatient SettingNot KnownOtherOther Health SettingOwn HomePublic PlaceSupported Accomodation
Description of Alleged Incident (including injuries)(mandatory)
Type (s) of alleged Abuse (mandatory)
Please list as many as apply / DiscriminatoryFinancialInstitutionalNeglect/Act of ommission by selfNeglect/Act of ommission by othersNot KnownPhysicalPsychological/EmotionalSexual
Is this an incident of Domestic Violence?(mandatory)
See Guidance
If Yes to above question has a DV (Domestic Violence Referral Form) been completed?
If this is an incident of Domestic Violence has a referral been made to the current contracted Domestic Violence Agency?
If this is an incident of Domestic Violence has a referral been made to MARAC?
See Guidance
Have the Police been informed? / Police informed of AbusePolice not informed
Police Reference Number
Name and Contact Details of All Witnesses
Details of Person (s) alleged to have harmed
Name of Person alleged to have harmed(mandatory)
If the Person alleged to have harmed is an Adult at Risk please enter their Care First ID Number
Provide contact details (if known) below
Relationship of the Person alleged to have harmed to the Adult at Risk(mandatory) / DaughterDay Care StaffDomiciliary care staffHealth care workerMain carerNeighbour/FriendNot knownOtherOther family memberOther vulnerable adultOther professionalPartnerResidential care staffSelf directed care staffsocial worker/care managersonspousestrangervolunteer/befriender
Does the Person alleged to have harmed live with the Adult at Risk?(mandatory) / Alleged perpetrator does not live with the victimAlleged perpetrator does live with the victim
Any other information relating to the Person alleged to have harmed
Is the Person alleged to have harmed aware of the Referral/Alert?(mandatory)
Details of 2nd Person alleged to have harmed (if applicable)
Name of 2nd Person alleged to have harmed (if applicable)
If the 2nd Person alleged to have harmed is a Adult atRisk, please enter their Care First/database ID Number
Provide contact details (if known) of 2nd Person alleged to have harmedbelow
Relationship of the 2nd Person alleged to have harmed to the Adult at Risk? / DaughterDay Care StaffDomiciliary care staffHealth care workerMain carerNeighbour/FriendNot knownOtherOther family memberOther vulnerable adultOther professionalPartnerResidential care staffSelf directed care staffsocial worker/care managersonspousestrangervolunteer/befriender
Does the 2ndPerson alleged to have harmed live with the Adult at Risk / Alleged perpetrator does not live with the victimAlleged perpetrator does live with the victim
Any other information relating to the 2ndPerson alleged to have harmed
Is the 2ndPerson alleged to have harmed aware of the Referral/Alert?
Mental Capacity and Consent
Does the Adult at Risk know that this Alert has been made?(mandatory) / Yes / No / N/K
Has the Adult at Risk been deemed to have mental capacity in relation to these safeguarding issues? (mandatory) / Yes / No / N/K
Does the Adult at Risk require an Advocate or IMCA? (mandatory) / Yes / No / N/K
Does the Adult at Risk give consent for an investigation to proceed? (mandatory) / Yes / No / N/K
Has the Adult at Risk agreed to information being shared with other agencies?(mandatory) / Yes / No / N/K
Adult at Risk and Carer View
What is the Adult at Risk’s desired outcome (s)?
Carer’s Comments
Summary
Summary of Actions and Risks
Brief Description of Action taken so far
Assessment of presenting risk and response
Details of Person notifying Alleged Abuse
Details of Person who notified the alleged abuse(mandatory)
List name; address; organisation and all contact details (telephone/email)
Source of Referral (mandatory) / Care quality commissionDay care staffDomiciliary care staffEducation/Training/Workplace establishmentFamily memberHousingNeighbourOtherOther service userOther social care staffPolicePrimary/community health staffProbation/Other criminal Justice systemResidential health staffSecondary health staffSelfSelf directed care staffSocial worker/Care Manager
Outcome and Authorisation
Outcome of Safeguarding Alert (mandatory)
Select from Outcomes below
Guidance: If a Safeguarding Strategy Discussion or Meeting is required please complete an SA2 Strategy Discussion or Meeting Form.
NFA - Inappropriate Safeguarding Referral
NFA - Did not wish to proceed (SA5)
NFA - Insufficient grounds for concern - No action under SGA (SA5)
Safeguarding Strategy Discussion or Meeting Required (SA2)
Does an SA5 Safeguarding Outcome Form need to be completed?(mandatory)
If ‘Yes’ please complete an SA5 Outcome Form on completion of this form
If this is the end of the Safeguarding process please record reasons below
Is the Alert Form ready to be authorised as agreed with your Manager? (mandatory)
Assessment Completion and Authorisation
Completed by / Staff CareFirst NumberRole/profession / Care / Support Team
Authorised by / Manager CareFirst Number
Role/profession / Care / Support Team
Assessor’s Signature
Supervisor’s Signature
Supervisor’s comments
Please send this completed Alert Form to:
Email:
Call; 0203 373 0440
Fax: 0208 430 1025 / 1405
SA1 Newham 2SASA!1SA0SA09 Page 1 Updated November 2012