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PROTECT - PERSONAL WHEN COMPLETE SA1 – Adult Safeguarding Concern and Notification Version 2 [07/04/2015] Page 1 of 12 ADULT SAFEGUARDING CONCERN & NOTIFICATION FORM – SA1 This SA1 form can be used: 1. To inform Wolverhampton City Council of a concern or incident that indicates an adult with care and support needs is; experiencing, or at risk of, abuse or neglect AND; is unable to protect themselves against abuse or neglect, or the risk of it, due to their care and support needs. All above points must be met prior to a referral of this nature. Or 2. To inform Wolverhampton City Council of information which suggests harm has occurred, or the potential for harm to occur existed, but the adult is no longer at risk or likely to be at risk, and therefore does not meet the criteria for a Section 42 Enquiry. Consideration MUST be given to risk to others. This is a notification – not all sections in this form will apply. If you have reason to believe a crime has been committed, this should be reported to the Police Service on telephone number 101. If there is an imminent risk to life, the report is of a sexual offence requiring prompt Police action with consideration to the preservation of evidence and/or forensic recovery, the suspect is still present, or an immediate response is otherwise required, this should be reported to the Police Service emergency line on telephone number 999. BEFORE COMPLETING THIS FORM, PLEASE REFER TO THE GUIDANCE SECTION AT THE END OF THE DOCUMENT Further copies of this form, West Midlands Safeguarding Policy and Procedure, and Local Guidance for Wolverhampton, can be found at www.wolverhampton.gov.uk

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PROTECT - PERSONAL WHEN COMPLETE

SA1 – Adult Safeguarding Concern and Notification Version 2 [07/04/2015]

Page 1 of 12

ADULT SAFEGUARDING CONCERN & NOTIFICATION FORM – SA1

This SA1 form can be used:

1. To inform Wolverhampton City Council of a concern or incident that indicates an adult with care

and support needs is;

experiencing, or at risk of, abuse or neglect AND;

is unable to protect themselves against abuse or neglect, or the risk of it, due to their

care and support needs.

All above points must be met prior to a referral of this nature.

Or

2. To inform Wolverhampton City Council of information which suggests harm has occurred, or the

potential for harm to occur existed, but the adult is no longer at risk or likely to be at risk, and

therefore does not meet the criteria for a Section 42 Enquiry. Consideration MUST be given to

risk to others.

This is a notification – not all sections in this form will apply.

If you have reason to believe a crime has been committed, this should be reported to the

Police Service on telephone number 101.

If there is an imminent risk to life, the report is of a sexual offence requiring prompt Police

action with consideration to the preservation of evidence and/or forensic recovery, the

suspect is still present, or an immediate response is otherwise required, this should be

reported to the Police Service emergency line on telephone number 999.

BEFORE COMPLETING THIS FORM, PLEASE REFER TO THE GUIDANCE SECTION AT THE

END OF THE DOCUMENT

Further copies of this form, West Midlands Safeguarding Policy and Procedure, and Local

Guidance for Wolverhampton, can be found at www.wolverhampton.gov.uk

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Adult: Who are you concerned about, or notifying us about?

First Name Surname D.O.B. / Age Gender

Home Address

Telephone Number(s)

Where is the person now (if different from above)

Ethnicity Religion (if known)

Preferred Language / Method of Communication Interpreter Required

Primary Client Group (if known - see guidance) Funding Authority (if known)

Professionals: Details of GP and/or any professionals currently involved

1. Name Role

Telephone Number(s)

2. Name Role

Telephone Number(s)

3. Name Role

Telephone Number(s)

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Additional Details: Additional background information

Are there concerns about the Adult’s mental capacity? Yes ☐ No ☐

If ‘Yes’ please give details:

Are there other adults with care and support needs who may be at risk?

Yes ☐ No ☐

If ‘Yes’ please give details, including names (if known) and a summary or risk and concerns:

Are there any children in the household? Yes ☐ No ☐

If ‘Yes’ please advise Children’s Referral Team on 01902 555392 if there are concerns regarding

the welfare of any children present.

In your view, is there any potential risk to anyone visiting the adult? Yes ☐ No ☐

If ‘Yes’ please give details:

Are there any difficulties in gaining access to the adult? Yes ☐ No ☐

If ‘Yes’ please give details:

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Potential Source of Harm: Person(s) causing, or giving potential for, harm

Source 1 Source 2 (if applicable)

Full Name

Age

Gender

Relationship to adult

Are they the main carer? Yes ☐ No ☐ Yes ☐ No ☐

Do they live with the adult?

Yes ☐ No ☐ Yes ☐ No ☐

Are they a member of staff, paid carer or volunteer?

Yes ☐ No ☐ Yes ☐ No ☐

What is their role?

Are they directly employed through a Direct Payment?

Yes ☐ No ☐ Yes ☐ No ☐

Which organisation are they employed by?

Does a referral need to be made to the DASM*?

Yes ☐ No ☐ Yes ☐ No ☐

Are there any other people at risk from the person causing harm?

Yes ☐ No ☐ Yes ☐ No ☐

*Designated Adult Safeguarding Manager

Does the allegation relate to an organisation/service? Yes ☐ No ☐

If ‘Yes’ please give details:

Does the incident need to be reported to the relevant regulatory body? Yes ☐ No ☐

If ‘Yes’ please give details (e.g. CQC):

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Nature of Concerns: detail current or likely risk(s) to the adult

Type of abuse suspected

☒ Financial ☐ Physical ☐ Emotional/Psychological

☐ Sexual ☐ Discriminatory ☐ Organisational

☐ Modern Slavery ☐ Self-Neglect ☐ Domestic Abuse

☐ Neglect or acts of omission (by a third party)

Details of Concerns and Risk to Adult:

Please refer to guidance (a) at the end of this document before completing this section

If additional space is required please continue on page 7

Date Concern or Incident arose (or Date Reported)

Type of location (see options in guidance)

Address of location of suspected Concern/Incident

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Initial Evaluation of Risk and Consent:

Is the adult you are concerned about aware that you are raising this concern?

Yes ☐ No ☐

Have they given their consent for this information to be shared? Please see guidance (b) at the end of this document before answering

Yes ☐ No ☐

If the adult is unable to give consent due to mental capacity, because it is not safe to consult with them at this stage, or for any other reason, please give details:

If you contacted the Police, were you given a crime number?

Yes ☐ No ☐ N/A ☐

If ‘Yes’ please provide number given:

Please provide details of any immediate actions taken to safeguard the adult, or any other action taken:

In your view, does consideration need to be given to an immediate support plan?

Yes ☐ No ☐

Please give details:

Please provide details of any person who the adult may see as a key contract in their life, who could assist in any possible safeguarding concern/enquiry, including contact information:

In your view, will the adult need an advocate? Please see guidance (c) at the end of this document before answering

Yes ☐ No ☐

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Does the adult feel safe at the moment? Yes ☐ No ☐ Unknown ☐

If ‘No’, what action does the adult want you to take:

In relation to this safeguarding concern, what goals and outcomes does the adult wish to achieve? If he/she is unable to answer, please include goals or desired outcomes as defined by any advocate or person acting in the adult’s best interests

Details of Person/Agency Raising the Concern:

Name Telephone Number

Address

Job Title Agency/Organisation (if applicable)

Person Category See guidance page 10

Are you/they willing to be contacted? Yes ☐ No ☐

If the person completing this form is not the person named in the box above please give details:

Please provide details of anyone else you or the person raising the concern has spoken to about the incident:

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Full Name (Print) Date of Concern

Signature

Please use this space to record any further information, including details that will not fit into sections above

For further information on raising appropriate concerns please contact a member of the Safeguarding

Team on 01902 553218 or email A&[email protected]

PLEASE FORWARD COMPLETED SA1 FORM TO:

Adult Care Access Point,

Tel: 01902 551199 FAX: 01902 553992

Email: [email protected] GCSX Email [email protected]

Out of office hours: Send SA1 form to the Emergency Duty Team on Tel 01902 552999 Fax : 01902

553201 Email: [email protected]

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Concerns being raised by New Cross Hospital or West Park Hospital for inpatients ONLY SA1 form

should be forwarded to Social Work Department at New Cross Hospital Tel: 01902 695780 Fax 01902

695729 Email : [email protected]

(For concerns raised by the hospital only, also forward a copy to the Hospital Safeguarding Team at

Corporate Services Building, New Cross Hospital)

GUIDANCE SECTION – Safeguarding Concern

THIS FORM SHOULD BE USED EVEN WHEN YOU HAVE REPORTED THE MATTER TO THE

POLICE. IF YOU BELIEVE A CRIME HAS OR MAY HAVE BEEN COMMITTED YOU SHOULD

REPORT THE MATTER TO THE POLICE ON 101 (OR 999 IF IT IS AN EMERGENCY). (A crime

could be a physical assault or a physical altercation between two service users who live in a care

home where harm has occurred, an allegation of domestic abuse, a sexual assault, an allegation of a

theft).

Please note this list is not exhaustive.

(a) ON COMPLETING THE WRITTEN REPORT/DETAILS OF CONCERNS The written report will need to include:

The date and time when the disclosure was made, or when you were told about/witnessed the incident

Who was involved, any other witnesses, (including service users and other staff if within a service)

Exactly what happened or what you were told, in the persons own words, keeping it factual and not interpreting what you saw or were told,

The views and wishes of the adult (see further guidance below) The appearance and behaviour of the adult and/or the person making the disclosure Any injuries observed Any actions and decisions taken at this point Any other relevant information e.g. previous incidents that have caused you concern

REMEMBER TO:

Include as much detail as possible Make sure the written report is legible and is of a quality that can be photocopied Make sure you have printed your name on the report and that it is signed and dated Keep the report factual as far as possible. However, if it contains your opinion or

assessment, it should be clearly stated as such and be supported by factual evidence. Information from another person should be clearly attributed to them.

Keep the report confidential, storing them in a safe and secure place until needed

(b) ON OBTAINING CONSENT OF THE ADULT Making safeguarding personal requires that the adult is placed at the centre of the process by

considering the wishes, views and feelings of the adult concerned. However, if you are seriously

concerned about the risks and the adult does not wish for this to be pursued within the

safeguarding process you should still give consideration to raising your concerns but clearly

documenting the adult’s views on this and evidence why you are still raising these concerns.

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Please consider public interest and duty of care – this may also mean reporting your concerns to

the Police if you believe a crime may have been committed.

Wherever it is safe to do so, speak to the adult to get their views on the concern or incident.

REMEMBER TO:

Follow good practice under the Mental Capacity Act when speaking to the adult. Assume they have mental capacity to make a decision about reporting this unless proven

otherwise. If it established that the adult lacks mental capacity, always ensure that you act in their Best

Interests with reference to the Mental Capacity Act 2005 Code of Practice.

REMEMBER:

Unless it is not safe or will increase the risk to the adult, it is always best practice to speak to the adult at as early a stage as possible to get their views and wishes on the concerns. This should help to guide what next steps should be taken and whether the concern should be reported as an adult safeguarding concern or should be dealt with by other means.

(c) ON ADVOCACY If the adult is considered to LACK mental capacity in relation to these specific decisions they

may be entitled to an Independent Mental Capacity Advocate under the Mental Capacity Act.

If the adult is considered to have mental capacity in respect of these specific decisions BUT has SUBSTANTIAL DIFFICULTY in being involved in the process and has no other suitable person to represent and support them then they should be considered for referral to an independent advocate. Substantial difficulty could be in any of the following: understanding information, retaining information, weighing up pros and cons and/or communicating.

GUIDANCE SECTION – Notification form

This form should also be used when you wish to notify Wolverhampton City Council of any concerns

but the adult is no longer at risk or likely to be at risk. For example, where there are allegations of

abuse/neglect and the adult has been discharged from a care home or hospital and will not be

returning. Where the adult is no longer at risk or likely to be at risk, further action may still need to be

taken although this will not be via a Section 42 Enquiry. E.g. a provider may be asked to undertake

their own investigation into the matter and report back to the appropriate agencies. Further

information sharing with partner agencies may also be necessary.

Guidance notes for selecting categories when completing this form:

Primary Client Group: Asylum Seekers Mental Health – Other

Dementia Physical Disability

Dual Sensory Loss Physical Disability/Frailty/Temporary Illness

Frailty and/or Temporary Illness Substance Misuse

Hearing Impairment Visual Impairment

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Learning Disability

Location of alleged incident/concern:

Please enter one or more of the following: Acute Hospital Care Home – Permanent

Care Home – Temporary Care Home with nursing – Permanent

Care Home with nursing – Temporary Community Hospital

Day Centre/Service Education/Training/Workplace Establishment

Home of person alleged to be causing harm Mental Health Inpatient Setting

Not Known Own Home

Other Other Health Setting

Public Place Supported Accommodation

Relationship of the person alleged to be causing harm to the adult at risk:

Please enter one or more of the following: Main Family Carer Partner

Other family Member Other Professional

Social Care Worker Health Care Worker

Volunteer/Befriender Other Vulnerable Adult

Service/Institution – Domiciliary Care Neighbour/Friend

Service/Institution – Care Home Stranger

Service/Institution – Day Care Not Known

Service/Institution – Other Service/Institution – Social Worker/Care Manager

Service/Institution – Individuals Budget/Direct Payments

Details/category of the person making the alert/referral: Please enter one of the following:

Education/Training/Workplace Establishment Regulators Care Quality Commission

Family Member Regulators Mental Health

Friend/Neighbour Self-Referral

Housing Social Care Day Care Staff

NHS – Mental Health Staff Social Care Domiciliary Staff

NHS Primary/Community Health Staff Social Care Other Staff

NHS – Secondary Health Staff Social Care Residential Care Staff

Other Self-Directed Care Staff

Other Service User Police

Social Worker/Care Manager

FOR WOLVERHAMPTON CITY COUNCIL USE ONLY

Managers Section

Is this a S42 Safeguarding Enquiry? Yes or No

Further information required (If the alerter is a professional, please return to them for further detail to

be added)

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Is this a notification form? Yes or No

Who needs to be notified of this information? (List not exhaustive)

Local Authority Designated Adult Safeguarding Manager (DASM)

Care Quality Commission

Quality Assurance and Compliance

Commissioning

Clinical Commissioning Group

Royal Wolverhampton NHS Trust

Black County Partnership Foundation Trust

West Midlands Police

West Midlands Fire Service

West Midlands Ambulance Service

Wolverhampton Housing

And/or the DASM for any of the above organisations