Residential/Nursing Care Staff Self Directed Care Staff Social Worker Or Care Manager Secondary Health Staff Primary Or Community Health Staff Day Care Staff Self Referral Mental Health Staff Other Service User Family Member Domiciliary Care Staff Other Social Care Staff Source of referral: Housing Services Friend/Neighbour London Ambulance Service Police GP Education/Training/Workplace Establishment Voluntary Agencies Care Quality Commission Other (Please Specify): CAD or Police/crime reference Has alleged abuse been referred to the Yes number? police? No Does the adult at risk have any special needs in relation to communication, physical access or mobility, medication or personal care: Yes No Does the adult have/need an advocate? PERSON ALLEGED TO HAVE CAUSED HARM DETAILS (Do Not put details if employed by the Local Authority) Do not speak with the perpetrator first without seeking advice from police or the Safeguarding Adults Manager. Include any Full name: nicknames Indicate if known at more than one address: Address : Postcode: (If known): Male: DOB: Age Gender: Female: Partner Social Worker Another Service User Domiciliary Care Staff Care Manager Is person alleged Health Care Worker Day Friend/Neighbour Other Social Care Staff to have caused Care Staff Stranger Self Directed Care Staff Volunteer/Befriender harm Institutional Other Statutory Agency Other Family Member Residential Care Staff Not Known Is the person alleged to have caused harm Yes Still living with adult at Yes the main carer? No risk? No Was person alleged to have caused harm living with the adult at risk at the time Yes of abuse? No Please provide details of relationship to adult at risk. Details of immediate action taken to safeguard the adult at risk (if any).
Source of referral: Residential/Nursing Care Staff Social Worker Or Care Manager Primary Or Community Health Staff Self Referral Other Service User Domiciliary Care Staff Housing Services London Ambulance Service GP Voluntary Agencies Self Directed Care Staff Secondary Health Staff Day Care Staff Mental Health Staff Family Member Other Social Care Staff Friend/Neighbour Police Education/Training/Workplace Establishment Care Quality Commission Other (Please Specify): Has alleged abuse been referred to the police? Yes No CAD or Police/crime reference number? Does the adult at risk have any special needs in relation to communication, physical access or mobility, medication or personal care: Does the adult have/need an advocate? Yes No PERSON ALLEGED TO HAVE CAUSED HARM DETAILS (Do Not put details if employed by the Local Authority) Do not speak with the perpetrator first without seeking advice from police or the Safeguarding Adults Manager. Full name: Include any nicknames Address : Indicate if known at more than one address: Postcode: (If known): DOB: Age Gender: Male: Female: Is person alleged to have caused harm Partner Domiciliary Care Staff Friend/Neighbour Self Directed Care Staff Statutory Agency Residential Care Staff Another Service User Health Care Worker Day Care Staff Stranger Institutional Other Family Member Social Worker Care Manager Other Social Care Staff Volunteer/Befriender Other Not Known Is the person alleged to have caused harm the main carer? Yes No Still living with adult at risk? Yes No Was person alleged to have caused harm living with the adult at risk at the time of abuse? Yes No Please provide details of relationship to adult at risk. Details of immediate action taken to safeguard the adult at risk (if any).
safeguarding_alert_form.docx