Safeguarding Adults Enquiry Form

This form is used to gather information about an alleged incident of abuse or neglect involving an adult at risk. It includes details about the incident, the adult at risk, and the alleged perpetrator. The form also collects information about the immediate safety measures taken and the desired outcomes of the safeguarding enquiry.

This form should be completed as fully as possible in order that
robust decisions can be made about the progression, or otherwise,
of the Safeguarding Adults Enquiry.
Person Role of Person:
completing
the form:
Date of Organisation:
referral to
Adult Social
Care:
Phone Type of service:
number:
Details of incident/suspected/actual abuse or neglect
Date of Who reported
alleged the
incident: alert/concern?
Time of Date of report:
alleged
incident:
Where did the incident
occur?
Details of the adult at risk
Name: Date of Birth:
Tereza
Lazo
Telephone: Ethnicity:
Address:
What is the adult’s primary reason for needing care and
support? (please tick)
Physical Sensory support: Support with
support: memory and
cognition:
Learning Asperger’s Autism support:
disability syndrome
support: support:
Mental health Social support No support
support: (includes support reason:
for
carers/substance
misusers):
Other health Pleas
condition: e
specif
y:

Any other
details about
the adult at
risk:
Details of the alleged perpetrator (where relevant)
Name: Relationship to
victim:
Date of birth: Ethnicity:
(1) Please give a detailed description of the incident (including times), all
people involved, witnesses and any other comments you feel are
relevant. If the concern relates to physical abuse please provide a body
map. (Maximum 200 words)
Tereza is an old woman of age 64 years, suffering from diabetes. Her physical
condition is poor, she has physical immobility, and she has difficulty to move in her
flat and prefers to sit on a chair surrounded by dirt all over. Tereza’s General
practitioner expressed concern regarding Tereza’s personal negligence which is a
form of self-neglect abuse. I am a health care professional who went to attend Tereza,
however I was not allowed to enter into her flat. She opened the door and she had an
unkempt appearance, her clothing was filthy with matted hair, she had sores on her
ankles which were infected. She looked frail and incapable to move, her hands were
shaking and she told me to drag a chair for her to sit at the doorway. She could not
reach out for a chair for herself due to physical immobility. She asked me to get her a
chair, however she wanted to care for her infected sores on her ankle.
bjb
Type of abuse (tick all that apply):
Physical: yes Sexual Psychological/emoti
onal
Financial/mate Neglect/omis Discriminatory
rial sion
Organisational Self-neglect Domestic
/institutional yes abuse/violence:
Modern Radicalisatio Other

slavery n/extremism
If other, please specify:
Is the victim at risk of further Ye No Unkno
abuse/neglect? (please tick) s wn
(2) What has been done to ensure the immediate safety of the alleged
victim(s) and others? Completing and submitting this form does not
constitute management of immediate risks. (Maximum 200 words)
Tereza’s conditions have been recorded and taken as evidence to be considered for care and support services.
She has been immediately provided health services from a local medical organisation to wash her infected
sores on her ankles and given proper medication. Cleanliness of her flat has been provided concern by a local
old age service provider. Cleaning services were immediately provided to clear the heaps of garbage in her
flat. Nursing professionals have been called for providing physical support to Tereza so as to enable her to
meet her daily basic activities. She was informed about self-neglect as a form of abuse and that it is necessary
for her to keep healthy through a healthy balanced lifestyle. The community neighbours are made aware and
told to remain alert of any vulnerable incidents involving Tereza. Whatever Tereza has shared with me has
been recorded and this recording has been presented to the adult service provider board members. A welfare
support service has been initiated to allow a nurse to stay with her to monitor her physical health and support
her.
Were the Police called? Yes N
o No
Please provide the outcome of the Police action and Police log number (if
available):
If the incident relates to domestic Ye No
abuse/violence, has the MARAC s
Checklist (CAADA-DASH) been
completed?
If yes, has a referral to MARAC been Ye No
considered? s
Please provide details, including
discussions with your agency’s
Single Point of Contact (SPOC) for
MARAC:
Please provide details of other agencies involved that will be able to help
with the safeguarding adults enquiry:
Are you aware that there have there been any Ye N

previous referrals made in relation to this s o no
adult at risk or alleged perpetrator?
If yes, please provide details (e.g. dates, type of abuse, action taken):
Are there any risks to others (other Ye No Unkn unknown
adults, children)? s own
Please provide details (also include who this information has been shared
with – e.g. Police, Children’s Social Care, MAPPA). If there are risks to
children you must notify Children’s Social Care.
The following section is crucial to determining the next steps in the safeguarding
adults enquiry and every attempt should be made to complete it as fully as.
Has the adult(s) at risk given consent Ye No
for this referral? s yes
If no, please confirm why you have not sought consent or are overriding
consent (please tick):
Public interest Risk of serious Suspected serious
(risks to others) harm crime
Adult at risk Ability to Seeking consent
lacks mental consent is would increase risks
capacity to affected by to the adult or others
provide consent threatening or
(best interest coercive
decision made) behaviour
Other, please provide details below:
(3) Do you think the adult at risk has mental Yes yes N
capacity in relation to making decisions about o
their safety?
If no, has a mental capacity assessment been Yes N
undertaken? o
Do you think the adult at risk would have Yes N
substantial difficulty in participating in the o
safeguarding adults process?
If yes, is there a suitable person Ye yes No Unkno
who could represent them? (e.g. s wn
family member, friend, advocate)
Please provide the name and contact details of this suitable person:
Tereza has been estranged by her daughter and therefore she lives all alone in her flat. Tereza could not share
the contact details of her daughter.

Has the adult at risk’s family been informed of Yes N
the concerns (where the adult has consented o No
to this)?
If you think the adult at risk may need support to participate in the
safeguarding adults process, please provide details of what support may
be required:
Physical as well as emotional support and educating her that safeguarding vulnerable
adults would lead to improved lifestyle and healthy aging.
(For Question 3 about consent maximum 200 words)
(4) What does the adult at risk (or their representative) say that they want
to happen as a result of this meeting and as a result of a safeguarding
enquiry (what are the client’s desired outcomes)? (Max words 200)
Tereza expresses that she wished to care for her infected sores on her ankle. Due to physical immobility she has
not being able to care for her sores. She expresses her wish to have a clean up activity of her flat where she
resides. Tereza shared that she had no knowledge of safeguarding. She has expressed her wish to receive care
and support. She has confidence that the care providers would provide her support to promote safety and
wellbeing.
Signe Date:
d:
Printe Time
d: :