Forms home Redbridge safeguarding adults referral form 1Introduction 2Details of person at risk3Details of concern4Who caused the harm5About you This referral form can be completed by a member of public or by any professional or volunteer from any agency. The exception to this is London Borough of Redbridge staff who should complete the internal form via CareFirst unless they do not have access to the system. In an emergency, or if you suspect you or someone else is in immediate danger, phone 999 to report to the Police. To help us to carry out enquiries into allegations of abuse, including neglect, please complete and provide as much information as possible. We will only contact you if you provide your consent and your details will be confidential. The form will be screened within 24 hours and if you have given your consent, we will contact you to let you know what actions are being taken and which social work team will be carrying out the enquiries. If contact is not made within three days, and you wish to be provided with an update, please send an email to Adults.Alert@redbridge.gov.uk We will speak to the person that you are concerned about to find out what their views are. We may also speak to other people to assist us in our enquiries but we will ask for permission first. If a crime has been committed, the concern may need to be reported to the police. Please note that we are not able to provide you with confidential personal information in line with Data Protection legislation. Who Does Safeguarding Adults Duties Apply to? An adult aged 18 and over who: has needs for care and support (whether or not the Council is meeting any of those needs) is experiencing, or at risk of abuse or neglect as a result of those care and support needs, is unable to protect themselves from either the risk of, or the experience of abuse or neglect Who is the person that you feel is at risk or is being abused? First name Last name Address Street address Address line 2 City/Town AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County Postcode Address typeFor example, sheltered accommodation, Warden controlled, care home, own homeTelephone number DescriptionFor example, gender, ethnicity and appearanceDate of birth DD slash MM slash YYYY Age (approximate if not know) How does the person communicate?For example, are they able to communicate verbally and if so, in what language? Do they require an interpreter? Do they have a speech or hearing impairment? How do they normally communicate?Please describe their care and support needs Details of concernWhat happened?For example, you may have observed, or it has been reported to you that the person named above is being hit or shouted at? Are any of the examples below occurring?Financial abuseAre there concerns that the relevant person is being financial abused? Are others taking money from him/her? Is there an unexplained shortage of money? Are there unexplained withdrawals from their bank accounts? Are they giving ‘unreasonable’ amounts of money away to cold callers, friends, family members, neighbours? Are they being coerced in relation to the management of their finances, property, or wills?Physical abuse Is the person named above being hit, assaulted, pushed, restrained and they are unable to protect themselves? Psychological abuseIs the person named above being threatened or humiliated? Are they being controlled, intimidated, shouted at? Are there issues of cyber bullying?Domestic violenceIs the person named above involved in a relationship or in a family where he/she is being exploited financially or emotionally? Are they being hit by the person they live with? Are they being taken advantage of sexually? Sexual exploitationAre there concerns of sexual harassment? Sexual exploitation can include being subjected to pornography or carrying out sexual acts that the person cannot give consent to? Modern slaveryDo you suspect the person named above is being treated like a slave? Are they being forced to work without being paid? Organisational abuseDoes the person named above live in a care home or attend a day centre or is in hospital and you are concerned that the quality of care being provided is poor? Are you concerned that the attitude of the staff is so poor that this is leading to the risk of abuse or neglect?NeglectIs the person named above being prevented from accessing health care or medical attention? Do they have access to food and drink? Do they have pressure ulcers that are not being treated? Self-neglectIs the person neglecting their personal care and health? Are there concerns about their home environment? Is the relevant person being forced to do things that they do not want to do and they are unable to protect themselves?When did it happen? Date DD slash MM slash YYYY Time : Hours Minutes Where did it happen?Did it happen in your home or in the person’s home? Did it happen in a care home? day centre? Supported living scheme? Hospital? Public place? Please provide as much details as possible and the names of the places. Have you discussed your concerns with the person that you making the referral about? Yes No How did they respond?Has the person you are concerned about given consent for you to report it? Yes No If consent has not been provided, raising a safeguarding concern may be justified where there is a vital risk to the person or others, where there is a public interest consideration or issue, or where a best interest decision needs to be made (where the adult lacks capacity to make the decision. If you still have concerns about abuse or neglect but in doubt, raise a safeguarding concern even if you do not feel able to speak to the person. Who do you think has caused the harm? First name Last name Description, for example, their ethnicity and appearanceRelationship to the person who is at risk of or is being abusedFor example, family member (please specify), paid carer, neighbour, friend, stranger.Do they live at the same address? Yes No Not known Immediate Safeguarding Adults PlanWhat measures are in place to ensure the safety of the relevant person and or others? About youWe may need to contact you to ask further questions. If you can provide us with your contact details, it will assist us in our enquiries. However, if you wish to remain anonymous, this would be respected. We will not share your details with anyone unless you give us permission to do so with named persons.Referrer name Role of referrer (if applicable) Address Street address Address line 2 City/Town AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County Postcode Email* Telephone number* Date of notification MM slash DD slash YYYY
