DCS_CONFCM_007
Outcome Form - SA6
Adult Safeguarding
Person Completing Outcome Form
Name:
Title/Role:
Address:
Details of Alleged Victim
ID / NHS No.:
Name:
Also Known as:
Address:
Post Code
Post Code
Tel:
Email:
Person who completed original Notification Form:
Name:
Date of original notification:
Team/Org/ Provider:
Tel:
DoB:
Marital Status:
Gender:
Religion:
Ethnicity:
Language:
Communication Issues:
Yes
No
Date of Investigation Outcome decision:
Investigation Outcome- on the balance of probabilities was the allegation:
Substantiated?
Not substantiated?
Partially substantiated?
Not determined/Inconclusive?
STRATEGY MEETINGS AND CASE CONFERENCES - Please record date(s) of and number per case:
Strategy discussion/meeting(s)
Review meetings
Case conferences
Institutional concerns meetings
For institutional or large scale investigations say which type of establishment / service:
Record vulnerable adult’s or advocate’s view of the outcome ideally in their own words or from
observation: e.g. I feel safe…. / I still feel at risk… / I did not want any action taken…. / eating better …
Quote/Observation: “
”
Outcome for vulnerable adult or vulnerable adult’s protection plan
Removed from property/service
Civil action
Community Care assessment / service
Increased monitoring
Management of access to finances
Referral to MARAC
Management of access to alleged perpetrator
Guardianship/use of M.H.Act
Application to change appointeeship
Review of SDS (any)
Move to increased/different care
Referral to Domestic Abuse Service (incl. Sunflower)
Court of Protection
Referral to Community Safety (Hate Incident)
Counselling / Training
Other (please specify)
Referral to Advocacy
Date of Protection Plan:
Alleged victim assessed no capacity
Name of lead agency to supervise Protection Plan:
Date of Protection Plan Review:
Responsible for review:
Page 1 of 2
Date Extracted: 13/07/2017
Form version 8.1 27Jan2012
‘This document contains information which is CONFIDENTIAL and may also be privileged. It is for the exclusive use of the intended recipient(s). If
you are not the intended recipient(s) please note that any form of distribution, copying or use of this document or the information in it is strictly
prohibited and may be unlawful.’
DCS_CONFCM_007
Outcome Form - SA6
Adult Safeguarding
Further work required / planned (include timescales):
Outcomes for Alleged Perpetrator – Individual or Organisation or Service
Referred to Police / for Police action
Removed from property / service
Criminal prosecution / Formal Caution
Community Care assessment / service
Action by Care Quality Commission
Carers’ assessment offered
Action by Contract Compliance
Referral to MAPPA
Referral to registration body
Referral to Court Mandated Treatment
Indep. Safeg. Auth (formerly POVA list)
Action under M.H. Act 1983 or 2007
Disciplinary action
Referred to PPU (Hate Crime)
Referred to Community Safety (Hate Incident)
Management action e.g. supervision / training
Referred to Sunflower Centre
Counselling/Training/Treatment
Exoneration
Management of access to vulnerable adult
Continued monitoring
Other (please specify)
No further action
Not Given
Date informed of Outcome decision (Parties below should normally be informed; else put “N/A”)
Date
By whom
Vulnerable adult
Carer
Staff member
Referrer
Details of person completing this form following their investigation:
Name:
Date:
Designation:
Office location:
Team:
Phone number:
Signature:
Team/Provider/Organisation- Investigator’s line manager’s confirmation that the investigation has been
completed and outcomes agreed and dated.
Name:
Date:
Designation:
Office location:
Team:
Phone number:
Signature:
This form plus supporting documentation i.e. protection plan, investigation report, meeting minutes, etc. must
be sent to the Safeguarding Adults Team immediately when the investigation is complete to enable NCC signoff. The information is also used for quality assurance and statistical analysis and is a vital data source for
Department of Health reporting.
Documents sent : Yes
No
Please send to:
Safeguarding Adults Team, Ground Floor, John Dryden House,
8 – 10 The Lakes, Northampton NN4 7DA
FAX: 01604 368134
AND
Where there is a safeguarding lead co-ordinator within your own organisation you must also send
a copy of the Outcome form to this person (please refer to your own organisation’s guidance)
Page 2 of 2
Date Extracted: 13/07/2017
Form version 8.1 27Jan2012
‘This document contains information which is CONFIDENTIAL and may also be privileged. It is for the exclusive use of the intended recipient(s). If
you are not the intended recipient(s) please note that any form of distribution, copying or use of this document or the information in it is strictly
prohibited and may be unlawful.’