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Safeguarding Alert

This form should be used to make a Safeguarding referral to Somerset County Council.

In an emergency always contact the police by dialling 999
If your contact with us requires an immediate response phone Somerset County Council on 0300 123 2224


Complete this form with as much information as possible.

Please select your organisation
  1. Organisation *

  2. Please note that if you select ‘Any other’ your form will be sent directly to the Adults team at Somerset County Council.If you select Somerset Partnership your form will be sent to your internal Somerset Partnership safeguarding team for internal checks and they will then submit this to Somerset County Council.
Section 1: Information about the person making the contact
  1. ()
Section 2: Information about the adult
  1. ()
  2. Has consent to share this information has been given by the adult? *
       
  3. Is it safe to contact this person?
       
  4. Does the person require an independent advocate?
       
  5. Do they have needs for care and support (whether or not the Local Authority is meeting any of those needs)
       
  6. Are they experiencing, or at risk of, abuse or neglect
       
  7. As a result of their care and support needs are they unable to protect themselves from either the risk of, or the experience of abuse or neglect?
       
  8. Have there been any previous safeguarding issues with this person?
       
Section 3: The person(s) / organisation / service that is believed to be the source of harm or abuse.
  1. If this is about self neglect or self harm you do not need to complete this section.
  2. ()
  3. / /
  4. Do they live with the adult at risk?
       
  5. Are they the main carer for the adult at risk?
       
  6. Do they know that an allegation has been made against them?
       
  7. Is this person also an adult at risk?
       
  8. Have there been previous safeguarding concerns in relation to this source?
       
Section 4: Immediate protection plan
  1. Have any actions been taken to make the person safe? *
       
  2. Have you consulted with the Police?
       
  3. Has medical intervention been sought?
       
Section 5: Mental Capacity
  1. Does the adult have capacity to understand their situation? (If yes, go to section 6) *
       
  2. If no, has a mental capacity assessment been undertaken?
       
  3. If no, are there plans to undertake a mental capacity assessment?
       
  4. Is this referral made in the persons ‘best interest’ under the Mental Capacity Act?
       
  5. Do they have a legally appointed representative
       
  6. Do they have an advocate?
       
  7. Does the person require an IMCA or other advocate?
       
  8. Type of advocate
       
  9. Does the person have the capacity to understand the nature of the safeguarding concerns?
       
  10. Does the person have the capacity to contribute to the decision making process in respect of the safeguarding concerns?
       
Section 6: Details of the alleged incident or concern
  1. Type of abuse (please tick all boxes that are appropriate) *









  2. Provide details of the people involved in the adults support network, for example family, neighbours, District nurse, GP. We may contact them to make further enquiries.
  3. Is there another person involved in their care?