Kent and Medway –
Safeguarding Adults Assessment, Risk Evaluation and Safeguarding Plan Form
Revised October 2012
Safeguarding Adults Form 1 (SA1)
Safeguarding Assessment -- Risk Evaluation -- Safeguarding Plan.
This form should be completed as part of a full investigation/assessment of adult protection concerns
SAFEGUARDING ADULTS – ASSESSMENT
Client details as at:
Completed by:
Client ID No:
Address:
Name:
Date of Birth:
Gender:
Ethnicity:
Phone:
Marital status of the client:
Date Assessment Started:
Location(s) assessment carried out (s):
1.
Date Assessment Completed:
Name of Key Worker:
2.
Team:
Contact details(tel):
Summary of concerns and previous history including any previous adult protection
incidents:
Outcome of time spent with and speaking to client:
Record of meeting with client / alleged victim.
(Please record the questions you asked. Include the client’s views about the allegations and what they would like to
happen as a result of your meeting with them. If you have not been able to spend time with or speak to the client
please explain why.
Appearance & demeanour of client:
Page 2 of 12
Mental Capacity
Is a Mental Capacity Act Assessment required?
Yes
No
Give reasons including decision making issues to be assessed:
Consent & information sharing
Were consent issues discussed?
Yes
If Yes, was consent given for
Yes
Information to be shared as
needed?
Details of any limitations in sharing:
No
Unable to consent
Yes, with limitations
Assessments of client’s strengths / needs:
Dependence/Independence (extent to which the person is able to meet their own needs:
Factors which restrict or may restrict independence
(nature & extent of disability/illness):
Page 3 of 12
No
N/A
Communication issues:
Support network (informal and formal networks of support including family and friends ):
Support / Care & relationship indicators:
Is support / care currently available:
Is support / care needed:
Name(s) (of person(s) or agency if relevant)
Relationship to client:
Is the client happy with the support / care they receive:
Describe any difficulties with support / care or the support / care relationship(s):
Is a full social/health assessment
required?
Yes
No
Is a carer’s assessment required?
Yes
No
Page 4 of 12
Environment in which risk arises
Describe Environment:
Comfort:
Suitability to individuals need (especially any environmental risk factors):
Signs/indicators of harm occurring or risk of harm:
For a fuller summary of the signs and indicators of harm and abuse please see:
WWW.kent.gov.uk/adultprotection policy, protocols and guidance documents
Neglect:
Physical: (additional body map may be required)
Psychological/emotional:
Financial:
Page 5 of 12
Sexual:
Discrimination and other factors:
Assessed Hazards i.e. types of occurrence or abuse that may cause harm/danger.
If possible discuss these with the client with the aim or empowering and encouraging them to
consider/decide how the hazard(s) may be reduced
Hazards
Reducing the hazard
1.
2.
3.
4.
Dangers i.e. possible outcomes associated with identified hazards and likelihood of
occurring (very likely, quite likely, not very likely, not at all likely)
Danger
Likelihood
1.
2.
3.
4.
Page 6 of 12
Views of significant others
Name:
Relationship to service user:
Views:
Details of any limitations in sharing information with the client:
Name:
Relationship to service user:
Views:
Details of any limitations in sharing information with the client:
Name:
Relationship to service user:
Views:
Details of any limitations in sharing information with the client:
Page 7 of 12
Outcome of discussion with other agencies
Name:
Organisation/agency:
Title:
Name:
Organisation/agency:
Title
Name:
Organisation/agency:
Title
Assessor(s) Name(s):
Date assessment completed:
Assessor(s) Signature(s):
Page 8 of 12
Summary Risk Evaluation
To be completed with the investigator/assessor(s)and the Designated Senior Officer
(DSO) on completion of this assessment
Guidance: Score each of the three sections and provide evidence to justify your
evaluation. Add scores together to determine an overall risk score to assist in determining
actions necessary to reduce identified risks, where possible.
1. Vulnerability - of the
individual who may be at
risk of harm
The person is fully able to take
action to protect themselves
Level of
risk
Score Evidence
Low
1
The person needs to support in
Moderate
some areas and has a supportive
network of family and friends
The person needs support in most Substantial
areas of their life/has limited net
work of support including family,
friends etc.
The person is unable to take
Critical
action to protect themselves and
has no access to appropriate help
or support
2. Overall impact - to the
individual who may be at
risk of harm
No evidence of harm or abuse
occurring
Level of
risk
Some evidence of harm occurring
or risk of harm occurring but
overall impact on individual is low
Evidence of serious risk of
harm/criminal offence has or may
of occurred
Potential life threatening/serious
criminal offence likely to
have/may have occurred
Moderate
2
3
4
Score Evidence
Low
1
2
Substantial
3
Critical
4
Page 9 of 12
3. Likelihood of future harm Level of
– to the individual
risk
No evidence of harm or abuse
occurring. No indicators present.
Low
Unlikely. No evidence of serious
harm, some indicators present
Moderate
Likely to occur unless significant
changes are made. Evidence of
harm occurring and /or number of
indicators suggesting harm
Very likely. Evidence of serious
harm occurring, indicators
suggest high risk of reoccurrence
unless significant changes are
made
Substantial
Score Evidence
1
2
3
Critical
4
Overall Risk Score (add scores from each of the three sections together):
The following is intended as a guide:
3-4
Low risk
No further action required at this time. Discuss and agree
actions with DSO.
5–6
Moderate
risk
Risk Assessment & Safeguarding plan required. DSO to
ensure plan co-ordinated, monitored and reviewed.
7-9
Substantial
risk
Multi agency risk assessment & safeguarding plan
required – to be agreed and coordinated by the DSO
10 - 12
Critical
Risk
Multi agency risk assessment & safeguarding plan
required – advice senior manager of the high risk
concerns.
Designated Senior Officers Name:
Designated Senior Officers Signature:
Date risk assessment agreed :
Page 10 of 12
Safeguarding Plan for the Client: (Please summarise any actions taken to empower / safeguard the
client e.g. information provided, change of service/carer, change of accommodation)
Action Taken/Planned/Agreed
By Whom
Date
Review Date
and by whom
1.
2.
3.
4.
Has the client consented to this plan?
Yes
Client was not deemed to have capacity to
consent to the protection plan at this time.
Additional
Comments
Name (s) and
Signature(s)
agreeing to
this plan:
Page 11 of 12
No
Review of Safeguarding Plan for the Client: (Please summarise any actions taken to empower /
safeguard the person e.g. information provided, change of service/care, change of accommodation).
Review of Actions
Taken/Agreed
Any changes
recommended
Date
1
2
3
4
5
Has the client consented to the revised plan?
Yes
Client was not deemed to have capacity to
consent to the protection plan at this time.
Comments
Name (s) and
Signature(s)
agreeing to
this plan:
Page 12 of 12
No
Further Review Date
and
who will be involved