Concerns/ Safeguarding
Staff/Volunteer
First Name
Last Name
Date of incident
-
Month
-
Day
Year
Date
Time of the incident
Date/time this was reported?
Dementia Active Member
First Name
Last Name
Who have you first reported the concerns to?
Date of Report
-
Month
-
Day
Year
Date
Please describe concerns (include date/s when issues causing concern occurred)
Please try and paint a picture around the concerns
Add here any conversation you have had with the member
Please try and paint a picture around this conversation
Official Use only - Name of Safeguarding Staff Member completing this section
First Name
Last Name
Categories
Please Select
Neglect & Acts of Omission
Self-Neglect
Neglect & Acts of Omission - Ongoing failure to meet a person’s basic physical or psychological needs
Rows
Not Satisfied
Somewhat Satisfied
Satisfied
Any thoughts?
Service Quality
Cleanliness
Responsiveness
Friendliness
Self-Neglect - A person living in a way that puts their health, safety, or well-being at risk.
Rows
Not Satisfied
Somewhat Satisfied
Satisfied
Any thoughts?
Service Quality
Cleanliness
Responsiveness
Friendliness
Action plan:
Action plan: Investigation: Any further conversations prior to decision re what level of risk is involved. e.g. conversation with the author of the report as written accounts often need filling in to get the full picture.Consultation with the lead safeguarding trustee unless the concern level is clearly mild.
Low Risk/Internal Response - Lower-level concern
Please Select
Neglects and acts of omission
Self Neglect
Physical Abuse
Sexual Abuse
Psychological Abuse
Domestic Abuse
Financial or Material Abuse
Organisational Abuse
Medication Errors
Trips and Falls
Incidents involving another person with care & support needs
Low impact incidents - Lower-level concern where threshold of further enquiries under safeguarding are unlikely to be met. However, agencies should keep a written internal record of what happened and what action was taken, following your own internal process. Where there are a number of low-level concerns consideration should be given as to whether the threshold is met for a safeguarding enquiry due to increased risk. Individual organisations should define this in writing i.e. three incidents in three months, three in five months, etc.
Medium Risk/Requires Consultation – Some Harm or Risk of Some Harm
Please Select
Neglects and acts of omission
Self Neglect
Physical Abuse
Sexual Abuse
Psychological Abuse
Domestic Abuse
Financial or Material Abuse
Organisational Abuse
Medication Errors
Trips and Falls
Incidents involving another person with care & support needs
Incidents at this level should automatically go to the lead safeguarding trustee who may seek informal advice from the local authority i.e. a social worker in the OSAB team.. After the conversation, they may request you formally report the concern.
High Risk/Always Reportable – Significant Harm or Risk of Significant Harm
Please Select
Neglects and acts of omission
Self Neglect
Physical Abuse
Sexual Abuse
Psychological Abuse
Domestic Abuse
Financial or Material Abuse
Organisational Abuse
Medication Errors
Trips and Falls
Incidents involving another person with care & support needs
Significant Harm or Risk of Significant Harm - Incidents at this level should be reported to your local authority and directed to the appropriate team. NB: You may need to contact the police/emergency services. This means it is highly likely the case will meet the criteria for a safeguarding enquiry (known as a Section 42 (Care Act 2014)
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