Confidential

Adult Safeguarding concerns

Please refer to the last page for guidance notes

Adults Details

Frameworki No: / NHS ID:
Name
Title / Date of Birth / dd/mm/yyyy
Gender / Please Select
Ethnicity / Please Select
Address
Postcode
Telephone no
Primary Support Reason / Please Select /
Social Support / Please Select /
Please give a brief overview of the adults care and support needs, health conditions and care being provided. Include support needed to aid communication (e.g. language/ hearing loss):

Next of Kin (or main person in their life) details:

Name
Address
Postcode
Telephone no
Mobile no
Email address
Relationship

Details of GP

Name of GP
Address of GP
Telephone no
Does this person live alone?
Yes No
Details:

Carers details (if applicable):

Name
Address

Details of Concern/Incident:

If there are any physical injuries consider completing a Body Map.
Date this happened: / dd/mm/yyyy
Has this happened before/is it an on-going concern?
Yes No Not Known
What are the concerns being raised and what are the risks for the Adult? Give brief details including information about the person(s) or service(s) thought to be the cause of risk (if known):
What, if any, action has already been taken to minimise any risk for the Adult?
Is the Adult aware of this concern being raised?
Yes No Not Known
Does the Adult consent to information being shared and concerns being raised?
Yes No Not Known
Adult’s Views and Wishes: If the adult is aware of the concern being raised, provide details of what their views are and what they would like to happen. If they are not aware, please explain why.
Are there any indications that the adult may not have capacity around this concern?
Yes No Not Known
Details:
Has the Person and/or service thought to be the cause of risk been informed about the concerns being raised?
Yes No
Details:
Are the Police aware or involved?
Yes No Not Known
Details, including Crime Reference Number:
Relevant persons or professionals involved, this may include, Care Quality Commission, Contracts, Multi-Agency Risk Assessment Conference, Other Local Authority, etc. – Please provide contact details.
Do you have concerns about other adults being at risk?
Yes No Not Known
If yes, please give details and describe any action taken to reduce risk to other adults:
Are there any known risks to workers or other adults/children who may visit?
Yes No Not Known
If yes, give details:

Details of the person raising concerns

Name
Address
Telephone no
Mobile no
Email address
Do you wish to remain anonymous when this information is shared? Please note that this may not always be possible, if you wish to discuss call Adults Carepoint in the first instance.
Yes No Not Known
Details:
Name/Signature of person raising concerns:
Date: / dd/mm/yyyy
Our centralised first point of contact is called ‘Adults’ Carepoint’
Phone: 01243 64 21 21
Email:
Opening hours: 9am–5pm Monday - Friday
Address: Adult Services Carepoint, West Sussex County Council, 2nd Floor The Grange, County Hall, Chichester, West Sussex, PO19 1RG
Emergency Out of Hours Contact: 01903 694422

Guidance Notes for completing the Safeguarding Adults’ concerns form.

  • When to raise a concern: If you are concerned that you or someone you know may be being abused, neglected or exploited, please say something. Abuse and neglect could be prevented if concerns are identified and raised as early as possible. The Sussex Safeguarding Adults Policy and Procedures (SSAPP) apply to adults who have care and support needs, and who are, or may be, unable to protect themselves from abuse or neglect because of their support needs. Please refer to the SSAPP for more details or contact Adults’ Carepoint on the details above.
  • Consent: Whenever possible seek agreement from the adult to share information and raise the concerns. If the adult declines, and you represent care and support services, you should inform them that you have a duty of care, and are bound by the codes of practice within your organisation (this does not apply if you are a member of the public), and you must inform the local authority, and where a crime is suspected, the Police/Adult Protection Team. If it has been difficult to seek the adult’s agreement, give a brief explanation why.
  • Mental Capacity:Provide any information regarding the adult’s ability to understand and make decisions about the safeguarding concerns. Provide any information you know about any relevant Mental Capacity Assessments.
  • Person/Service thought to be the cause of risks:While the focus of safeguarding is the adult, it is important that all individuals affected have their rights protected. Wherever possible, the person/service thought to be the cause of risk should be informed that a safeguarding concern is being raised so that they can provide an initial response. However, the person should not be informed or approachedif this could increase risk for the adultor others.

Adult Safeguarding form – Raising a Safeguarding Concern1

Version 1.3June 2016