<p> Page 1 of 6</p><p>Safeguarding Adults Concern (SAC) Form</p><p>Care Act 2014</p><p>For notification of suspected or actual abuse or neglect to an individual person</p><p>Please do not save a copy of this form to use as a template to your own storage area as this form will be updated as and when required; any copies you hold may be out of date, and, if submitted, will slow the process of raising the concern. </p><p>For further information, documents and guidance to support the completion of this form, please access the Sunderland City Council website. </p><p>A - DETAILS OF THE ADULT ALLEGED TO BE EXPERIENCING OR AT RISK OF ABUSE AND/OR NEGLECT (NAMED ADULT) A1 Named Adult: </p><p>A2 Address (including post code): </p><p>A3 Date of Birth: </p><p>A4 Tel No: </p><p>A5 Gender: Choose from drop down menu</p><p>A6 Ethnicity: Choose from drop down menu</p><p>A7 Marital Status: Choose from drop down menu</p><p>A8 Reason the Named Adult is in Choose from drop down menu need of support: </p><p>B - DETAILS OF THE ALLEGED ABUSE AND/OR NEGLECT B1 Date the alleged abuse and/or neglect took place </p><p>B2 Please provide brief details of the alleged abuse and/or neglect being reported now</p><p>B3 If you are aware of any previously alleged abuse and/or neglect, please provide brief details</p><p>B4 Category of alleged abuse and/or neglect (it is Choose from drop down menu essential that all organisations complete this and state the main category here)</p><p>B5 Please indicate any additional categories of alleged Choose from drop down menu</p><p>SAC V1.4 (01/04/17) Page 2 of 6</p><p> abuse and/or neglect? Choose from drop down menu Choose from drop down menu</p><p>B6 Threshold tier on first assessment of the alleged Choose from drop down menu abuse and/or neglect</p><p>When completing this, you must refer to the Safeguarding adults ADASS thresholds guidance (a guide to assessing thresholds and to decision making - Low, Significant, Very Significant or Critical)</p><p>B7 Is the Named Adult at risk of continuing or further Choose from drop down menu abuse and/or neglect?</p><p>B8 Action Taken (please Completing and submitting this form does not provide details of all constitute management of immediate risks. actions that have been taken to ensure immediate safety of the Named Adult. Please include details if police were involved and of all safeguarding measures already put in place)</p><p>B9 Given the action you have taken, what is your Choose from drop down menu assessment of the threshold tier?</p><p>Please ensure that you always use the latest Safeguarding adults ADASS thresholds guidance (a guide to assessing thresholds and to decision making) </p><p>B10 Has the action you have taken reduced the level of Choose from drop down menu risk? </p><p>B11 Please provide names and telephone numbers of other people or organisations involved who will be able to help with this concern and any subsequent Safeguarding Adults Enquiry</p><p>B12 Where did alleged abuse and/or neglect take place? Choose from drop down menu</p><p>Please ensure that ‘Other’ is recorded only when none of the other options apply. </p><p>B13 Are there any children who could be at risk as a result Choose from drop down menu of the alleged abuse and/or neglect being reported on this form?</p><p>B14 Where children could be at risk, has someone Choose from the drop down responsible for the safeguarding of children and young menu</p><p>SAC V1.4 (01/04/17) Page 3 of 6</p><p> people been made aware? </p><p>B15 Where it has been identified that children are at risk, please state  who has been contacted and when; or,  if no one has been contacted, state why</p><p>C - FURTHER DETAILS OF THE NAMED ADULT C1 Are there any concerns, generally, in relation to the Choose from drop down menu mental capacity of the Named Adult? </p><p>If the answer is No, please move to C5</p><p>C2 If there are concerns in relation to the mental capacity of the Named Adult, please provide details</p><p>C3 Has the Named Adult had any Mental Choose from drop down menu Capacity Act assessments? If the answer is No, please move to C5</p><p>C4 If the answer to C3 is Yes, please provide brief details of  each decision that had to be made which necessitated an assessment; and  the outcome of each assessment i.e. if the Named Adult did or did not have mental capacity at the relevant time to make a decision</p><p>C5 Is the Named Adult aware that this Choose from drop down menu concern is being raised with the Local Authority? </p><p>C6 Has the Named Adult been consulted Choose from drop down menu with and consented to this concern being raised with the Local Authority? </p><p>C7 Is the Named Adult to be supported by an advocate, Choose from drop down family member or friend? menu</p><p>C8 If the Named Adult is to be supported by someone, please provide their  full name  address  telephone number  status i.e. advocate, family member or friend</p><p>C9 Are there any concerns in Choose from drop down menu</p><p>SAC V1.4 (01/04/17) Page 4 of 6</p><p> relation to Domestic Violence/Abuse for the Named Adult? </p><p>C10 If the answer to C9 above is Yes, what action has been taken?</p><p>C11 Please provide details of any caring or co caring arrangements that need to be considered</p><p>C12 State any specific needs of the Named Adult (e.g. interpreter, access/mobility assistance)</p><p>D - DETAILS OF THE PERSON COMPLETING THIS FORM D1 Name: </p><p>D2 Job Title: </p><p>D3 Name of Organisation: </p><p>D4 Type of Organisation: </p><p>D5 Work Address: </p><p>D6 Tel No: </p><p>D7 E-mail: </p><p>D8 Secure E-mail (if applicable): </p><p>D9 Please provide the name and contact details of the original alerter in your organisation</p><p>E - NAME OF THE PERSON WHO IS ALLEGED TO HAVE NEGLECTED OR ABUSED OR PLACED THE NAMED ADULT AT RISK OF NEGLECT OR ABUSE (ALLEGED PERPETRATOR) E1 Name: </p><p>E2 Address (if known): </p><p>E3 Date of Birth: </p><p>E4 Place of Work (if relevant): </p><p>E5 In what way is the alleged perpetrator known to the Choose from drop down menu Named Adult? </p><p>E6 Is the alleged perpetrator also a person who has Choose from drop down menu care and support needs?</p><p>SAC V1.4 (01/04/17) Page 5 of 6</p><p>E7 Are there any concerns in relation to the mental Choose from drop down menu capacity of the alleged perpetrator?</p><p>E8 If there are any concerns in relation to the mental capacity of the alleged perpetrator, please provide details</p><p>F - GENERAL INFORMATION F1 Please provide the name of the Safeguarding Lead for your organisation</p><p>F2 Have you discussed this concern with your Safeguarding Lead? If so, when?</p><p>F3 Date this form is completed </p><p>F4 Does the concern relate to the quality of service? Choose from drop down menu</p><p>Name of person completing this form: </p><p>Signed: </p><p>If you are sending this form from a sunderland.gov.uk or a GENTOO e-mail, please send to [email protected]</p><p>If you are not sending this form to/from a sunderland.gov e-mail account, please choose the most appropriate option from those below – </p><p> If you have a secure compatible account (GCSX, GSI, NHS.NET, CJX, PNN), send to [email protected] (please note that only those that are compatible with GCSX email addresses will get through to the GCSX account. </p><p> If you don’t have a secure compatible account, send to [email protected] using an encrypted 7zip attachment. 7 Zip, Sunderland Local Authority’s preferred encryption solution, can be downloaded from a variety of sources. NB: this form must never be sent without encryption (see Protecting information in transit – ensuring the security of e-mailed customer records).</p><p>SAC V1.4 (01/04/17) Page 6 of 6</p><p> If you are unable to send by any of the above, please fax to 0191 553 1688; you will receive confirmation of safe receipt. If you do not receive this confirmation, you are responsible for ensuring it has arrived. </p><p>Address of Sunderland Safeguarding </p><p>Sunderland City Council, Room 2.48, Floor 2, Civic Centre, Burdon Road, Sunderland. SR2 7DN</p><p>PLEASE NOTE: The Customer Support Network telephone number: 0191 5205552 is not to be used by members of partner organisations when alerting abuse and/or neglect; this is primarily used by members of the public. Partner organisations are required to complete the Safeguarding Adults Concern Form located in the Sunderland City Council website and choose the most appropriate option for sending; as outlined above. </p><p>SAC V1.4 (01/04/17)</p>