Care providers safeguarding referral form
A safeguarding concern under section 42 of the care act (2014) should be raised when you are aware of or have been informed about an adult who:
- Has care and support needs
- Is experiencing, or is at risk of, abuse or neglect
- Is unable to protect themselves because of those needs
Please ensure all relevant details are provided to support appropriate safeguarding action.
Who Should Use This Form?
This form is to be used by the following types of care providers:
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Nursing Homes
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Domiciliary Care (Home Care)
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Supported Living Services
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Extra Care Housing (Assisted Living)
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Day Centres / Day Services
Important Information Before You Submit
Please Note:
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If a crime is in progress or has been committed and / or someone is in imminent danger, call 999.
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This form should not be used to inform us about concerns solely related to suicidal ideation or self-harm.
If you are concerned about an adult who is at risk of harm due to their mental health, please contact the adults GP or:
- North Staffordshire Combined Healthcare - Crisis Care Centre: Call 0800 032 8728 and choose option 1 (covers Stoke-on-Trent, Newcastle-under-Lyme, Staffs Moorlands)
- South Staffordshire urgent NHS mental health helpline:
Call 0808 196 3002 Email mhsi.staffordshire@mpft.nhs.uk (covers Stafford, Stone, Rugeley, Cannock, South Staffs, Lichfield, Burton, Uttoxeter, Tamworth)
- Staffordshire and Stoke-on-Trent Safeguarding Enquiry Procedures state:
"There is no requirement for care providers to raise a safeguarding concern in relation to single instances of poor practice where no lasting harm or distress has occurred and where there is a plan for protecting the adult from the risk of harm.
The expectation is that providers will undertake their own internal investigations and take the appropriate disciplinary or remedial actions, as well as reporting significant incidents to the relevant regulators in line with regulations and legislation."
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You should regularly review any incidents logged which have not been raised as a safeguarding concern to identify themes, trends or lessons learned.
This will support the implementation of preventive action to help mitigate the risk of further incidents.
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For further information about when to raise a Safeguarding Adults Concern, please visit MIDOS.
Need Help Completing This Form?
For guidance on how to complete the form and what information is required, please visit:
Provider referral guidance
Raising a Safeguarding Concern
If you would like to raise a new safeguarding concern, please use the button below to do so. Ensure that all relevant details are provided and clearly outlined in the appropriate sections to help us understand the nature of the concern and respond appropriately.
This form is for non-urgent safeguarding concerns only. It may take up to 24 hours for the Safeguarding Team to receive and review your referral.
For any referrals that require immediate attention, please contact 0345 604 2719