Safeguarding Adults Concern (SAC) Form
Page 1 of 6
Safeguarding Adults Concern (SAC) Form
Care Act 2014
For notification of suspected or actual abuse or neglect to an individual person
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as a template to your own storage area as this form will be updated as and when required; any copies you hold may be out of date, and, if submitted, will slow the process of raising the concern.
For further information, documents and guidance to support the completion of this form, please access the Sunderland City Council website.
A - DETAILS OF THE ADULT ALLEGED TO BE EXPERIENCING OR AT RISK OF ABUSE AND/OR NEGLECT (NAMED ADULT)A1 / Named Adult:
A2 / Address (including post code):
A3 / Date of Birth:
A4 / Tel No:
A5 / Gender: / Choose from drop down menuFemaleMaleTransgenderNot Known
A6 / Ethnicity: / Choose from drop down menuArabAsian/Asian British - BangladeshiAsian/Asian British - ChineseAsian/Asian British - IndianAsian/Asian British - PakistaniAsian/Asian British - Any other AsianBlack or Black British - AfricanBlack or Black British - CaribbeanBlack/Afr/Carib/Black Brit-other Black/Afr/CaribInformation not yet obtainedMixed - White and AsianMixed - White and Black AfricanMixed - White and Black CaribbeanMixed-other mixed/multiple ethnic backgroundRefusedWhite - BritishWhite - Gypsy or Irish TravellerWhite - IrishWhite - Any Other White BackgroundAny Other Ethnic Group
A7 / Marital Status: / Choose from drop down menuCivil PartnershipDivorcedLiving togetherMarriedSingleWidowedUnknownSeparated
A8 / Reason the Named Adult is in need of support: / Choose from drop down menuAlcohol useAsylum Seeking AdultCarerDrug useLearning DisabilityMental HealthMemory and cognitionNoneOtherPhysical Support: Access and Mobility onlyPhysical Support: Personal Care SupportSensory Dis-DualSensory Dis-HearingSensory Dis-VisualSupport for Social Isolation
B - DETAILS OF THE ALLEGED ABUSE AND/OR NEGLECT
B1 / Date the alleged abuse and/or neglect took place
B2 / Please provide brief details of the alleged abuse and/or neglect being reported now
B3 / If you are aware of any previously alleged abuse and/or neglect, please provide brief details
B4 / Category of alleged abuse and/or neglect (it is essential that all organisations complete this and state the main category here) / Choose from drop down menuDiscriminatoryDomesticFinancial or MaterialModern SlaveryNeglect and Acts of OmissionOrganisational PhysicalPrevent (Radicalisation/Extremism)PsychologicalSelf NeglectSexual Sexual exploitation
B5 / Please indicate any additional categories of alleged abuse and/or neglect? / Choose from drop down menuDiscriminatoryDomesticFinancial or MaterialModern SlaveryNeglect and Acts of OmissionOrganisational PhysicalPrevent (Radicalisation/Extremism)PsychologicalSelf NeglectSexual Sexual exploitation
Choose from drop down menuDiscriminatoryDomesticFinancial or MaterialModern SlaveryNeglect and Acts of OmissionOrganisational PhysicalPrevent (Radicalisation/Extremism)PsychologicalSelf NeglectSexual Sexual exploitation
Choose from drop down menuDiscriminatoryDomesticFinancial or MaterialModern SlaveryNeglect and Acts of OmissionOrganisational PhysicalPrevent (Radicalisation/Extremism)PsychologicalSelf NeglectSexual Sexual exploitation
B6 / Threshold tier on first assessment of the alleged abuse and/or neglect
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) / Choose from drop down menuLowSignificantVery significantCritical
B7 / Is the Named Adult at risk of continuing or further abuse and/or neglect? / Choose from drop down menuYesNoNot known
B8 / Action Taken (please provide details of all 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) / Completing and submitting this form does not constitute management of immediate risks.
B9 / Given the action you have taken, what is your assessment of the threshold tier?
Please ensure that you always use the latest Safeguarding adults ADASS thresholds guidance (a guide to assessing thresholds and to decision making) / Choose from drop down menuLow SignificantVery SignificantCritical
B10 / Has the action you have taken reduced the level of risk? / Choose from drop down menuAction taken and risk reducedAction taken and risk remainsAction taken and risk removedNo action takenUnknown/unable to ascertain
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
B12 / Where did alleged abuse and/or neglect take place?
Please ensure that ‘Other’ is recorded only when none of the other options apply. / Choose from drop down menuAlleged Perpetrator's Own HomeCare Home - NursingCare Home - ResidentialDay Care, Leisure/Community Ctres, GP's, Dentist'sExtra Care or Sheltered Housing SchemeHospital - acuteHospital - communityHospital - mental healthNamed Adult's Own HomeOtherOther People's HomePublic Place/Public TransportRelative's Home (Named Adult not living there)Schools/Colleges/Adult Education/LibrariesSupported accommodationWorkplace/Businesses/Office/Pub
B13 / Are there any children who could be at risk as a result of the alleged abuse and/or neglect being reported on this form? / Choose from drop down menuYesNoNot known
B14 / Where children could be at risk, has someone responsible for the safeguarding of children and young people been made aware? / Choose from the drop down menuYesNo
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
C - FURTHER DETAILS OF THE NAMED ADULT
C1 / Are there any concerns, generally, in relation to the mental capacity of the Named Adult?
If the answer is No, please move to C5 / Choose from drop down menuYesNo Not Known
C2 / If there are concerns in relation to the mental capacity of the Named Adult, please provide details
C3 / Has the Named Adult had any Mental Capacity Act assessments? If the answer is No, please move to C5 / Choose from drop down menuYes No
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
C5 / Is the Named Adult aware that this concern is being raised with the Local Authority? / Choose from drop down menuYesNoNot Known
C6 / Has the Named Adult been consulted with and consented to this concern being raised with the Local Authority? / Choose from drop down menuYesNoNot Known
C7 / Is the Named Adult to be supported by an advocate, family member or friend? / Choose from drop down menuYesNoNot Known
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
C9 / Are there any concerns in relation to Domestic Violence/Abuse for the Named Adult? / Choose from drop down menuYes NoNot Known
C10 / If the answer to C9 above is Yes, what action has been taken?
C11 / Please provide details of any caring or co caring arrangements that need to be considered
C12 / State any specific needs of the Named Adult (e.g. interpreter, access/mobility assistance)
D - DETAILS OF THE PERSON COMPLETING THIS FORM
D1 / Name:
D2 / Job Title:
D3 / Name of Organisation:
D4 / Type of Organisation:
D5 / Work Address:
D6 / Tel No:
D7 / E-mail:
D8 / Secure E-mail (if applicable):
D9 / Please provide the name and contact details of the original alerter in your organisation
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:
E2 / Address (if known):
E3 / Date of Birth:
E4 / Place of Work (if relevant):
E5 / In what way is the alleged perpetrator known to the Named Adult? / Choose from drop down menuAdult Son or DaughterChild (under 18)Ex-spouse or Ex-partnerFamily member including in-lawFriend, Acquaintance or NeighbourIndependent Service ProviderMain Family Carer (informal)Not knownOther professionalOther Service UserPaid Worker/CarerSpouse or partnerStrangerVolunteer/Befriender from a voluntary agency
E6 / Is the alleged perpetrator also a person who has care and support needs? / Choose from drop down menuYesNoNot Known
E7 / Are there any concerns in relation to the mental capacity of the alleged perpetrator? / Choose from drop down menuYesNoNot Known
E8 / If there are any concerns in relation to the mental capacity of the alleged perpetrator, please provide details
F - GENERAL INFORMATION
F1 / Please provide the name of the Safeguarding Lead for your organisation
F2 / Have you discussed this concern with your Safeguarding Lead? If so, when?
F3 / Date this form is completed
F4 / Does the concern relate to the quality of service? / Choose from drop down menuNoYes
Name of person completing this form:
Signed:
If you are sending this form from a sunderland.gov.uk or a GENTOO e-mail, please send to
If you are not sending this form to/from a sunderland.gov e-mail account, please choose the most appropriate option from those below –
· If you have a secure compatible account (GCSX, GSI, NHS.NET, CJX, PNN), send to (please note that only those that are compatible with GCSX email addresses will get through to the GCSX account.
· If you don’t have a secure compatible account, send to 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).
· 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.
Address of Sunderland Safeguarding
Sunderland City Council,
Room 2.48, Floor 2, Civic Centre, Burdon Road, Sunderland. SR2 7DN
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.
SAC V1.4 (01/04/17)