Safeguarding Adults Referral Form Part 1 - Reading Borough Council

SECTION 4b. LOCATION OF ABUSE (Tick only one as applicable)[ ] Person at risk’s own home [ ] Other person’s home[ ] Residential Care Home [ ] Alleged Perpetrator’s Home[ ] Nursing Care Home [ ] Public Place[ ] Day Service [ ] Service delivered in a community setting[ ] Mental Health Inpatient Setting [ ] Retail Setting[ ] Community Hospital [ ] Education/Training/Workplace[ ] Acute Hospital [ ] Supported Accommodation[ ] Other Health Setting [ ] Any other setting not listed above (including notknown)SECTION 4c. WHO RAISED THE CONCERN? (Tick one only as applicable)If the concern was raised by an organisation, please give details in Section 4d below.[ ] Self Referral [ ] Residential Care Staff [ ] Self Directed Care Staff[ ] Family Member [ ] Health - Primary/Community Health Staff [ ] Housing[ ] Friend/Neighbour [ ] Health - Secondary Health staff [ ] Police[ ] Other Service User [ ] Health - Mental Health Staff [ ] Education/Training/Workplace[ ] Domiciliary Staff [ ] Social Worker / Care Manager [ ] Care Quality Commission[ ] Day Care Staff [ ] Social Care Staff - Other [ ] OtherSECTION 4d. ORGANISATION TYPE OF SERVICE PROVIDEDName:Type: (e.g. Domiciliary Care, Residential Care, Day Care)SECTION 5a. SOURCE OF POSSIBLE RISK OR ABUSE (Alleged abuser)Surname:Forenames:Title: Gender: [ ] Male [ ] Female Date of Birth:Address:Name of organisation:Does the alleged abuser live with the person at risk?Is the alleged abuser the main carer?Is the alleged abuser also a vulnerable adult?SECTION 5b.Yes / NoYes / NoYes / NoINDIVIDUAL OR ORGANISATION BELIEVED TO BE SOURCE OF RISK (Alleged abuser)Is the Individual / Organisation that is the source of risk, known to the vulnerable adult or not known?[ ] Known [ ] Not knownIf the source of risk is a service provider:Is it social care / privately paid for service? Yes / NoWhat type of service is provided? (e.g. Day Care, Residential, Domiciliary etc)Please select source of risk from list below:[ ] Relative / family carer [ ] Social Care Staff – Care Management & Assessment[ ] Individual – known, but not related [ ] Primary Health Care e.g. GP.[ ] Individual – unknown / stranger [ ] Secondary Health Care e.g. A&E, Hospital OT, Hospice, Ward.[ ] Other service user [ ] Community Health Care e.g. District Nurse[ ] Other vulnerable adult [ ] Other public sector[ ] Police [ ] Other private sector[ ] Regulator [ ] Voluntary (e.g.registered charity, community or self-help group etc)SECTION 6.Are there multiple victims?MULTIPLE VICTIMS - ALERTS TO OTHER AUTHORITIES AND CQCHave other Local Authorities been alerted? Pleasegive details:Yes / NoBy whom:Page 2 of 3Date:

Has the Care Quality Commission been alerted? By whom: Date:SECTION 7. DETAILS OF PERSON COMPLETING FORMNamePhone No.Agency/Team/Clinical AreaEmail addressDate and time discussed with LineManager/Senior member of staff(this should not delay referral)Name of line Manager/Senior member of staffSECTION 8. FUTURE ACTIONS (To be completed by the Local Authority)[ ] Not Going Further Under Safeguarding Date:Reason:[ ] Urgent Strategy Meeting Required Date:[ ] Assigned Team for Assessment Date:[ ] Strategy Meeting Not Required Date:[ ] Agreed by (Manager) Date:NOW SEND THIS ALERT FORM TO THE AREA WHERE THE ALLEGED ABUSE HAPPENED:ReadingSafeguarding Adults, Community Care Services, Level 5, Civic Offices, Reading, RG1 7AEsafeguarding.adults@reading.gov.ukWest BerkshireSafeguarding Adults Team, Care Commissioning, Housing and Safeguarding, West Street House, WestStreet, Newbury, RG14 1BZsafeguardingadults@westberks.gov.ukWokinghamAssessment Service Duty Team, Wokingham Borough Council, Civic Offices, Shute End, Wokingham,RG40 1BN CCMailboxcontactdutydesk@wokingham.gov.ukIf you are completing this form in an emergency and out of office hours, send it to:Emergency Duty Service for Berkshireedt@bracknell-forest.gov.ukFax no: 01344 786535Tel: 01344 786543West of Berkshire Safeguarding Adults Referral Form Part 1- 1 st April 2013Date due for review 31 st September 2013Page 3 of 3