CCMS Safeguarding Concern Form

This form should be completed when there is cause for concern, no matter how trivial and given to the CCMS Safeguarding Lead as soon as possible.

Sometimes we have a “feeling” or a “niggle” at the back of our minds and this form must be used to outline those potential issues.

Details of Client
Client's Name Client's Name First Last
Details of the person reporting the concerns
Full Name Full Name First Last
What is your relationship to the Client?

What is your relationship to the Client? Support Worker/PA Case Manager Family Member Other (Please specify)
Your Phone Number
Email
Who is the responsible Case Manager?
Date of the concern/disclosure: (Approximate if not known) Date of the concern/disclosure:
(Approximate if not known) / DD / MM YYYY
Is this the exact date, or an approximate date?

Is this the exact date, or an approximate date? Exact date Approximate date
Details of the concern/disclosure:
Is the individual at immediate risk of further harm/abuse?

Is the individual at immediate risk of further harm/abuse? Yes No Unknown
Is the individual over the age of 16?

Is the individual over the age of 16? Yes No
Care Act 2014 Safeguarding Criteria (Adults only)
Does the alleged victim have care and support needs?

Does the alleged victim have care and support needs? Yes No
Are they experiencing or at risk of experiencing abuse/neglect?

Are they experiencing or at risk of experiencing abuse/neglect? Yes No
Are they able to protect themselves from the abuse/neglect?

Are they able to protect themselves from the abuse/neglect? Yes No
Type of abuse/neglect (check those that apply):

Type of abuse/neglect (check those that apply): Physical Abuse inc. Medication Errors Domestic Abuse Sexual Abuse Neglect Self-neglect Financial Abuse Institutional Abuse Emotional/psychological Abuse Discrimination Modern Slavery
Action taken:
Any other relevant information:
Is there any other relevant documentation associated with this?
Upload relevant files (optional)
Signature

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Full Name

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Today's Date: Today's Date: / DD / MM YYYY

Safeguarding Concern Reference

Disclaimer

This MachForm, together with any attachments, is for the exclusive and confidential use of the addressee(s). Any other distribution, use or reproduction without the prior consent of Care and Case Management Services (CCMS Ltd) is unauthorised and strictly prohibited. If you have received this MachForm in error, please notify CCMS by e-mail immediately (safeguarding@ccms.org.uk) and delete it from your computer without making any copies.

Care and Case Management Services Ltd, The Old Smithy, 1 North Road, Stokesley, North Yorkshire, TS9 5DU; Company Number: 6079954 England; Registered address: 1 Suffolk Way, Sevenoaks, Kent, TN13 1YL.

CCMS Safeguarding Concern Form

CCMS Safeguarding Concern Form

Details of Client

Details of the person reporting the concerns

Care Act 2014 Safeguarding Criteria (Adults only)

Signature