Safeguarding Adults Form 1 (SA1)
Safeguarding Assessment -- Risk Evaluation -- Safeguarding Plan.
This form should be completed as part of a full investigation/assessment of adult protection concerns
SAFEGUARDING ADULTS – ASSESSMENTClient details as at: / Completed by:
Client ID No:
Name:
Date of Birth:
Gender:
Ethnicity:White BritishWhite IrishWhite and Black CarribeanWhite and Black AfricanWhite and AsianIndianPakistaniBangladeshiCarribeanAfricanChineseAny other ethnic groupAsian OtherBlack OtherInfo DeclinedMixed OtherUnknownWhite Other
Marital status of the client: / Address:
Phone:
Date Assessment Started:
Date Assessment Completed: / Location(s) assessment carried out (s):
1.
2.
Name of Key Worker: / Team: / Contact details(tel):
Summary of concerns and previous history including any previous adult protection incidents:
Outcome of time spent with and speaking to client:
Record of meeting with client / alleged victim.
(Please record the questions you asked. Include the client’s views about the allegations and what they would like to happen as a result of your meeting with them. If you have not been able to spend time with or speak to the client please explain why.
Appearance & demeanour of client:
Mental Capacity
Is a Mental Capacity Act Assessment required? / Yes / No
Give reasons including decision making issues to be assessed:
Consent & information sharing
Were consent issues discussed? / Yes / No / Unable to consent
If Yes, was consent given for
Information to be shared as
needed? / Yes / Yes, with limitations / No / N/A
Details of any limitations in sharing:
Assessments of client’s strengths / needs:
Dependence/Independence (extent to which the person is able to meet their own needs:
Factors which restrict or may restrict independence
(nature & extent of disability/illness):
Communication issues:
Support network (informal and formal networks of support including family and friends):
Support / Care & relationship indicators:
Is support / care currently available: / Is support / care needed:
Name(s) (of person(s) or agency if relevant) / Relationship to client:
Is the client happy with the support / care they receive:
Describe any difficulties with support / care or the support / care relationship(s):
Is a full social/health assessment required? / Yes No
Is a carer’s assessment required? / Yes No
Environment in which risk arises
Describe Environment:
Comfort:
Suitability to individuals need (especially any environmental risk factors):
Signs/indicators of harm occurring or risk of harm:
For a fuller summary of the signs and indicators of harm and abuse please see:
policy, protocols and guidance documents
Neglect:
Physical: (additional body map may be required)
Psychological/emotional:
Financial:
Sexual:
Discrimination and other factors:
Assessed Hazards i.e. types of occurrence or abuse that may cause harm/danger.
If possible discuss these with the client with the aim or empowering and encouraging them to consider/decide how the hazard(s) may be reduced
Hazards / Reducing the hazard
Dangers i.e. possible outcomes associated with identified hazards and likelihood of occurring (very likely, quite likely, not very likely, not at all likely)
Danger / Likelihood
Views of significant others
Name: / Relationship to service user:
Views:
Details of any limitations in sharing information with the client:
Name: / Relationship to service user:
Views:
Details of any limitations in sharing information with the client:
Name: / Relationship to service user:
Views:
Details of any limitations in sharing information with the client:
Outcome of discussion with other agencies
Name:
Title: / Organisation/agency:
Name:
Title / Organisation/agency:
Name:
Title / Organisation/agency:
Assessor(s) Name(s):
Assessor(s) Signature(s): / Date assessment completed:
Summary Risk Evaluation
To be completed with the investigator/assessor(s)and the Designated Senior Officer (DSO) on completion of this assessment
Guidance: Score each of the three sections and provide evidence to justify your evaluation. Add scores together to determine an overall risk score to assist in determining actions necessary to reduce identified risks, where possible.
- Vulnerability - of the individualwho may be at risk of harm
The person is fully able to take action to protect themselves / Low
/ 1
The person needs to support in some areas and has a supportive network of family and friends / Moderate / 2
The person needs support in most areas of their life/has limited net work of support including family, friends etc. / Substantial / 3
The person is unable to take action to protect themselves and has no access to appropriate help or support / Critical / 4
- Overall impact - to theindividualwho may be at risk of harm
No evidence of harm or abuse occurring / Low
/ 1
Some evidence of harm occurring or risk of harm occurring but overall impact on individual is low / Moderate / 2
Evidence of serious risk of harm/criminal offence has or may of occurred / Substantial / 3
Potential life threatening/serious criminal offence likely to have/may have occurred / Critical / 4
- Likelihood of future harm – to the individual
No evidence of harm or abuse occurring. No indicators present. / Low
/ 1
Unlikely. No evidence of serious harm, some indicators present / Moderate / 2
Likely to occur unless significant changes are made. Evidence of harm occurring and /or number of indicators suggesting harm / Substantial / 3
Very likely. Evidence of serious harm occurring, indicators suggest high risk of reoccurrence unless significant changes are made / Critical / 4
Overall Risk Score (add scores from each of the three sections together):
The following is intended as a guide:
3 - 4 / Low risk / No further action required at this time. Discuss and agree actions with DSO.5 – 6 / Moderate
risk / Risk Assessment & Safeguarding plan required. DSO to ensure plan co-ordinated, monitored and reviewed.
7 - 9 / Substantial risk / Multi agency risk assessment & safeguarding plan required – to be agreed and coordinated by the DSO
10 - 12 / Critical
Risk / Multi agency risk assessment & safeguarding plan required – advice senior manager of the high risk concerns.
Designated Senior Officers Name:
Designated Senior Officers Signature:
Date risk assessment agreed :
Safeguarding Plan for the Client:(Please summarise any actions taken to empower / safeguard the client e.g. information provided, change of service/carer, change of accommodation)
Action Taken/Planned/Agreed / By Whom / Date / Review Dateand by whom
1.
2.
3.
4.
Has the client consented to this plan? / Yes / No
Client was not deemed to have capacity to consent to the protection plan at this time.
Additional
Comments
Name (s) and Signature(s) agreeing to this plan:
Review ofSafeguarding Plan for the Client:(Please summarise any actions taken to empower /
safeguard the person e.g. information provided, change of service/care, change of accommodation).
Review of Actions Taken/Agreed / Any changes recommended / Date / Further Review Date andwho will be involved
1
2
3
4
5
Has the client consented to the revised plan? / Yes / No
Client was not deemed to have capacity to consent to the protection plan at this time.
Comments
Name (s) and Signature(s) agreeing to this plan:
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