Concerns Stage 1: Advice for Submitting an Adult Safeguarding Concern
1. You need to recognise if what you are seeing or hearing is potential abuse or neglect
There are many forms and ways that adult abuse and neglect can occur, so we should not be constrained by definitions and terminologies. Adult abuse is also often complex involving more than one type of abuse occurring at any one time.
However, the most common forms of abuse are:
Physical abuse +
Types of physical abuse
- Assault, hitting, slapping, punching, kicking, hair-pulling, biting, pushing.
- Rough handling.
- Scalding and burning.
- Physical punishments.
- Inappropriate or unlawful use of restraint.
- Making someone purposefully uncomfortable (e.g. opening a window and removing blankets).
- Involuntary isolation or confinement.
- Misuse of medication (e.g. over-sedation).
- Forcible feeding or withholding food.
- Unauthorised restraint, restricting movement (e.g. tying someone to a chair).
Possible indicators of physical abuse
- No explanation for injuries or inconsistency with the account of what happened.
- Injuries are inconsistent with the person’s lifestyle.
- Bruising, cuts, welts, burns and/or marks on the body or loss of hair in clumps.
- Frequent injuries.
- Unexplained falls.
- Subdued or changed behaviour in the presence of a particular person.
- Signs of malnutrition.
- Failure to seek medical treatment or frequent changes of GP.
Domestic violence or abuse +
Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence, or abuse between two people aged 16 or over who are ‘personally connected’. This includes those who are, or have been, intimate partners, or relatives, regardless of gender or sexual orientation. This may include psychological, physical, sexual, financial, emotional abuse, and so-called honour-based violence. See the full definition here: Domestic Abuse Act 2021 - Statutory Guidance July 2022
LSAB Adult Safeguarding and Domestic Abuse 7 minute briefing
Domestic Abuse and Older People – Information from Safe Lives
Free online training for Female Genital Mutilation and Forced Marriage: Virtual College
Raise awareness of the signs of Coercive Control by using Lewisham's - Can you see the signs of coercive control? - Poster
Also see this very useful Web Page: Lewisham Safeguarding Adults Board - Domestic Abuse
Coercive or controlling behaviour is a core part of domestic violence. Coercive behaviour can include:
- Acts of assault, threats, humiliation and intimidation.
- Harming, punishing, or frightening the person.
- Isolating the person from sources of support.
- Exploitation of resources or money.
- Preventing the person from escaping abuse.
- Regulating everyday behaviour.
Possible indicators of domestic violence or abuse
- Low self-esteem.
- Feeling that the abuse is their fault when it is not.
- Physical evidence of violence such as bruising, cuts, broken bones.
- Verbal abuse and humiliation in front of others.
- Fear of outside intervention.
- Damage to home or property.
- Isolation – not seeing friends and family.
- Limited access to money.
Sexual abuse +
Types of sexual abuse
- Rape, attempted rape or sexual assault.
- Inappropriate touch anywhere.
- Non- consensual masturbation of either or both persons.
- Non- consensual sexual penetration or attempted penetration of the vagina, anus or mouth.
- Any sexual activity that the person lacks the capacity to consent to.
- Inappropriate looking, sexual teasing or innuendo or sexual harassment.
- Sexual photography or forced use of pornography or witnessing of sexual acts.
- Indecent exposure.
Possible indicators of sexual abuse
- Bruising, particularly to the thighs, buttocks and upper arms and marks on the neck.
- Torn, stained or bloody underclothing.
- Bleeding, pain or itching in the genital area.
- Unusual difficulty in walking or sitting.
- Foreign bodies in genital or rectal openings.
- Infections, unexplained genital discharge, or sexually transmitted diseases.
- Pregnancy in a woman who is unable to consent to sexual intercourse.
- The uncharacteristic use of explicit sexual language or significant changes in sexual behaviour or attitude.
- Incontinence not related to any medical diagnosis.
- Self-harming.
- Poor concentration, withdrawal, sleep disturbance.
- Excessive fear/apprehension of, or withdrawal from, relationships.
- Fear of receiving help with personal care.
- Reluctance to be alone with a particular person.
Psychological or emotional abuse +
Types of psychological or emotional abuse
- Enforced social isolation – preventing someone accessing services, educational and social opportunities and seeing friends.
- Removing mobility or communication aids or intentionally leaving someone unattended when they need assistance.
- Preventing someone from meeting their religious and cultural needs.
- Preventing the expression of choice and opinion.
- Failure to respect privacy.
- Preventing stimulation, meaningful occupation or activities.
- Intimidation, coercion, harassment, use of threats, humiliation, bullying, swearing or verbal abuse.
- Addressing a person in a patronising or infantilising way.
- Threats of harm or abandonment.
- Cyber bullying.
Possible indicators of psychological or emotional abuse
- An air of silence when a particular person is present.
- Withdrawal or change in the psychological state of the person.
- Insomnia.
- Low self-esteem.
- Uncooperative and aggressive behaviour.
- A change of appetite, weight loss/gain.
- Signs of distress: tearfulness, anger.
- Apparent false claims, by someone involved with the person, to attract unnecessary treatment.
Financial or material abuse +
Types of financial or material abuse
- Theft of money or possessions.
- Fraud, scamming.
- Preventing a person from accessing their own money, benefits or assets.
- Employees taking a loan from a person using the service.
- Undue pressure, duress, threat or undue influence put on the person in connection with loans, wills, property, inheritance or financial transactions.
- Arranging less care than is needed to save money to maximise inheritance.
- Denying assistance to manage/monitor financial affairs.
- Denying assistance to access benefits.
- Misuse of personal allowance in a care home.
- Misuse of benefits or direct payments in a family home.
- Someone moving into a person’s home and living rent free without agreement or under duress.
- False representation, using another person's bank account, cards or documents.
- Exploitation of a person’s money or assets, e.g. unauthorised use of a car.
- Misuse of a power of attorney, deputy, appointeeship or other legal authority.
- Rogue trading – eg. unnecessary or overpriced property repairs and failure to carry out agreed repairs or poor workmanship.
Possible indicators of financial or material abuse
- Missing personal possessions.
- Unexplained lack of money or inability to maintain lifestyle.
- Unexplained withdrawal of funds from accounts.
- Power of attorney or lasting power of attorney (LPA) being obtained after the person has ceased to have mental capacity.
- Failure to register an LPA after the person has ceased to have mental capacity to manage their finances, so that it appears that they are continuing to do so.
- The person allocated to manage financial affairs is evasive or uncooperative.
- The family or others show unusual interest in the assets of the person.
- Signs of financial hardship in cases where the person’s financial affairs are being managed by a court appointed deputy, attorney or LPA.
- Recent changes in deeds or title to property.
- Rent arrears and eviction notices.
- A lack of clear financial accounts held by a care home or service.
- Failure to provide receipts for shopping or other financial transactions carried out on behalf of the person.
- Disparity between the person’s living conditions and their financial resources, e.g. insufficient food in the house.
- Unnecessary property repairs.
Modern slavery +
Types of modern slavery
- Human trafficking.
- Forced labour.
- Domestic servitude.
- Sexual exploitation, such as escort work, prostitution and pornography.
- Debt bondage – being forced to work to pay off debts that realistically they never will be able to.
Possible indicators of modern slavery
- Signs of physical or emotional abuse.
- Appearing to be malnourished, unkempt or withdrawn.
- Isolation from the community, seeming under the control or influence of others.
- Living in dirty, cramped or overcrowded accommodation and or living and working at the same address.
- Lack of personal effects or identification documents.
- Always wearing the same clothes.
- Avoidance of eye contact, appearing frightened or hesitant to talk to strangers.
- Fear of law enforcers.
Further Home Office information on identifying and reporting modern slavery
LSAB Modern Slavery & Human Trafficking Web Page
Lewisham Modern Slavery Victim Care Pathway
Discriminatory abuse +
Types of discriminatory abuse
Unequal treatment based on age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex or sexual orientation (known as protected characteristics’ under the Equality Act 2010)
- Verbal abuse, derogatory remarks or inappropriate use of language related to a protected characteristic.
- Denying access to communication aids, not allowing access to an interpreter, signer or lip-reader.
- Harassment or deliberate exclusion on the grounds of a protected characteristic.
- Denying basic rights to healthcare, education, employment and criminal justice relating to a protected characteristic.
- Substandard service provision relating to a protected characteristic.
Possible indicators of discriminatory abuse
- The person appears withdrawn and isolated.
- Expressions of anger, frustration, fear or anxiety.
- The support on offer does not take account of the person’s individual needs in terms of a protected characteristic.
For more information, please refer to:
Discriminatory Abuse Webinar
Discriminatory Abuse Self- Assessment September 2023
Stop Hate UK
Metro Charity
Lewisham Speaking Up
Organisation or institutional abuse +
Types of organisational or institutional abuse
- Discouraging visits or the involvement of relatives or friends.
- Run-down or overcrowded establishment.
- Authoritarian management or rigid regimes.
- Lack of leadership and supervision.
- Insufficient staff or high turnover resulting in poor quality care.
- Abusive and disrespectful attitudes towards people using the service.
- Inappropriate use of restraints.
- Lack of respect for dignity and privacy.
- Failure to manage residents with abusive behaviour.
- Not providing adequate food and drink, or assistance with eating.
- Not offering choice or promoting independence.
- Misuse of medication.
- Failure to provide care with dentures, spectacles or hearing aids.
- Not taking account of individuals’ cultural, religious or ethnic needs.
- Failure to respond to abuse appropriately.
- Interference with personal correspondence or communication.
- Failure to respond to complaints.
Possible indicators of organisational or institutional abuse
- Lack of flexibility and choice for people using the service.
- Inadequate staffing levels.
- People being hungry or dehydrated.
- Poor standards of care.
- Lack of personal clothing and possessions and communal use of personal items.
- Lack of adequate procedures.
- Poor record-keeping and missing documents.
- Absence of visitors.
- Few social, recreational and educational activities.
- Public discussion of personal matters.
- Unnecessary exposure during bathing or using the toilet.
- Absence of individual care plans.
- Lack of management overview and suppor.t
Including neglect and poor care practice within and institution or specific care setting such as a hospital or care home, for example, or in relation to care provided in one’s own home.
NICE Guidelines: Safeguarding in Care Homes
Guidance for Reporting Falls Events as Adult Safeguarding Concerns May 2024
If there any concerns about the behaviour and conduct of a professional working with an adult at risk of abuse and neglect, then this should be reported as a Safeguarding Concern under the 'Public Interest Duty', and if this work is a regulated activity, then a referral to the Disclosure and Barring Service (DBS) should also be considered: DBS Briefing
Neglect and acts of omission +
Types of neglect and acts of omission
- Failure to provide or allow access to food, shelter, clothing, heating, stimulation and activity, personal or medical care.
- Providing care in a way that the person dislikes.
- Failure to administer medication as prescribed.
- Refusal of access to visitors.
- Not taking account of individuals’ cultural, religious or ethnic needs.
- Not taking account of educational, social and recreational needs.
- Ignoring or isolating the person.
- Preventing the person from making their own decisions.
- Preventing access to glasses, hearing aids, dentures, etc.
- Failure to ensure privacy and dignity.
Possible indicators of neglect and acts of omission
- Poor environment – dirty or unhygienic.
- Poor physical condition and/or personal hygiene.
- Pressure sores or ulcers.
- Malnutrition or unexplained weight loss.
- Untreated injuries and medical problems.
- Inconsistent or reluctant contact with medical and social care organisations.
- Accumulation of untaken medication.
- Uncharacteristic failure to engage in social interaction.
- Inappropriate or inadequate clothing.
Safeguarding adults protocol: pressure ulcers and raising a safeguarding concern - GOV.UK
Stop the Pressure: NHS Improvement
Pressure Ulcer Panel Process - University Hospital Lewisham Dec 2020
Pressure Ulcer Panel Process - In the Community Sep 2022
Guidance for Reporting Falls Events as Adult Safeguarding Concerns May 2024
Self-neglect +
Types of self-neglect
- Lack of self-care to an extent that it threatens personal health and safety.
- Neglecting to care for one’s personal hygiene, health or surroundings.
- Inability to avoid self-harm (including suicidal ideation).
- Failure to seek help or access services to meet health and social care needs.
- Inability or unwillingness to manage one’s personal affairs.
Indicators of self-neglect
- Very poor personal hygiene.
- Unkempt appearance.
- Lack of essential food, clothing or shelter.
- Malnutrition and/or dehydration.
- Living in squalid or unsanitary conditions.
- Neglecting household maintenance.
- Hoarding.
- Collecting a large number of animals in inappropriate conditions.
- Non-compliance with health or care services.
Inability or unwillingness to take medication or treat illness or injury.
Self-harm and suicide
The very serious concerns for a person who carries out an act of self-harm or attempts suicide may not constitute a Safeguarding Concern in isolation.
Agencies must consider the individuals whole circumstances, as they may be displaying other characteristics which also constitute self-neglect, as well as the self-harm or suicidal ideation.
Agencies should consider an individual’s physical and emotional ability to self-care. If a person is suffering from mental instability, it is likely this will have an overall impact on their wellbeing, which could include characterises of self-neglect detailed above.
The local self-neglect practice guidance (link below) does not include issues of risk associated with deliberate self-harm and suicidal ideation, although more information can be found here on this subject: Get Help with Mental Health
LSAB Hoarding & Self-Neglect Web Page
Multi-Agency Self-Neglect Policy, Practice Guidance and Procedures June 2024
Self-Neglect High Risk Panel - Risk Assessment & Action Plan Template.
London Fire Brigade: Help for Hoarders - Fire Safety Tips
Guidance for Reporting Falls Events as Adult Safeguarding Concerns May 2024
Read our Homelessness and Safeguarding Information page for guidance, tools and advice.
Lewisham Suicide Prevention Strategy 2022-25
2. Talk to the adult (unless it is not safe to do so)
Think about how you ask questions and how you can improve your understanding of a person's life circumstances: Lewisham Safeguarding Adults Board - Professional Curiosity
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Safeguarding Principle - Protection
What does this means for the professionals: Adults are offered ways to protect themselves, and there is a co-ordinated response to adult safeguarding.
What does this means for the adult: "I am provided with help and support to report abuse. I am supported to take part in the safeguarding process to the extent to which I want and which I am able".
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2.1 If the adult does not wish to report the abuse: Are they in immediate danger or risk of serious harm?
Has a crime been committed? If so, and the adult is in immediate danger or risk of serious harm, then this should be reported to the Police immediately. Help to keep the adult safe until the Police respond. The adult does not need to give their consent under these circumstances due to ‘vital interest’ considerations (immediate danger or risk of serious harm).
Is the adult experiencing a mental health crisis? If so then see this webpage for further advice on how to respond and Get Help with Mental Health
How to Report Your Concerns About an Adult
Are others, including children in immediate danger or risk of serious harm? If so, then this should be reported to Police immediately, and consideration also give to reporting this to Children’s Services. Help to keep the child safe until the Police respond. The adult(s) does not need to give their consent under these circumstances due to ‘public interest’ considerations (others, including children are in immediate danger or risk of serious harm).
How to Report Your Concerns About a Child
Safeguarding and promoting the welfare of children and adults most at risk of abuse and neglect is a shared responsibility. The ‘Think Family’ approach should be used by all practitioners who should consider the needs of the whole family, including young carers, taking into account family circumstances and responsibilities. Existing professional relationships should be viewed as a chance to identify risk, refer to colleagues in other services, and to use targeted support to help prevent problems from escalating and therefore potentially limiting harm.
Refer to the: The Think Family page where you will find the Lewisham Think Family Protocol, the Think Family Practice Guidance and resources.
2.2 Consider if this matter meets the Section 42 (1) criteria within the Care Act 2014 as a Safeguarding Concern:
a. do I have reasonable cause to suspect that the adult has needs for care and support; and
b.do I have reasonable cause to suspect that the adult is at risk, or, experiencing abuse or neglect.
It must be noted that the third criteria (c) under the legal duty for a Section 42 Enquiry (1) is not relevant 'for the referrer' at the Concern Stage. This is for the local authority to determine, but referrers should pass on any evidence to help support decision making.
c. as a result of those needs is unable to protect himself or herself against the abuse or neglect or the risk of it.
LGA/ADASS Guidance on What Constitutes a Safeguarding Concern - Sept 2020
Local Government Association - What Constitutes a Safeguarding Concern: FAQ's
If this is not a crime and these criteria appear to have been met, then speak to the adult to get their views on the Safeguarding Concern or the incident. It is always best to support the adult in reporting abuse themselves. Find out what they want to happen next.
If a decision is made not to refer to the Local Authority the individual agency must make a record of the concern and any action taken. Concerns should be recorded in such a way that repeated, low level harm incidents are easily identified and subsequently referred.
Not referring under safeguarding adults’ procedures does not negate the need to report internally or to regulators/commissioners as required, and if care providers are using this guidance, it is important to note that all Safeguarding Concerns must be notified to the Local Authority.
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Safeguarding Principle - Empowerment
What does this mean for the professionals: Adults are encouraged to make their own decisions and are provided with information and support.
What does this mean for the adult: "I am consulted about the outcomes I want from the safeguarding process and these directly inform what happens".…………………………………………………………………………………………………………………………...............................
If this criteria does not appear to have been met, but you are unsure, then you must seek further advice including from the Local Authority. How to Report Your Concerns About an Adult
If you are certain that this criteria has not been met, then consider what other pathways, options or services could be used to help support this adult, including providing relevant information? Record your decision-making in relation to this subject in an appropriate manner.
3. Seek the adult’s consent to submit a Safeguarding Concern to the Local Authority
Seek the adult’s consent to submit the Safeguarding Concern and explain this may mean that several agencies may gain access to their personal details:
- Read The Caldicott Principles. These are relevant if you work in health and social care.
- Also see Information Sharing page which is full of advice, guidance and the local Information Sharing Agreement.
- Does the adult have the mental capacity to consent to the Safeguarding Concern being submitted now?
- Is there a need to provide statutory advocacy: Advocacy 7 Minute Briefing March 2023
- Is there any possibility that the adult has/ is suffering from any type of coercion, control, threat, duress or pressure from another person(s) which may mean they refuse consent?
- Does mental capacity (including executive capacity) need to be assessed or reviewed? For more information read: Decision Making and Mental Capacity (NICE Guidelines), Supported decision-making toolkit for people with communication difficulties Practicable steps for people with communication difficulties and Oldham SAB's Executive Functioning Guidance
- Give due regard to the adult’s views and wishes, including their desired outcomes, even if Best Interest Decisions have been made linked to the Mental Capacity Act. For more information read: Local Government Association - Making Safeguarding Personal Toolkit including on the six Safeguarding Principles and Alcohol Change UK Cognitive Impairment Guide and Alcohol Change UK How to use legal powers to safeguard highly vulnerable dependent drinkers guide.
- If the adult does have the mental capacity to consent to the Safeguarding Concern being submitted, but refuses, professionals must be careful that they consider how to keep the adult safe. This may be particularly relevant in domestic abuse cases if they continue to submit the concern. The adult must be informed that a Safeguarding Concern has been submitted, unless it is unsafe or impractical to do so.
- A Safeguarding Concern can still be submitted without the adult’s consent if ‘vital’ or ‘public’ interest considerations apply (see 2.1 above). For more information read: LGA/ADASS Guidance on What Constitutes a Safeguarding Concern - Sept 2020
- If the adult meets the safeguarding duty criteria, and is at risk of significant harm, and it is deemed they do have the mental capacity to refuse consent and to not engage with any Safeguarding Enquiry, then the local authority should consider seeking legal advice and the use of the Court of Protection, and or Inherent Jurisdiction: 39 Essex Chambers: Guidance on Use of Inherent Jurisdiction
4. Gather as much information as possible
Having spoken to the adult (as above) and determined their views, wishes and desired outcomes. Also gather as much information as possible from other relevant sources and documentation:
- Does anyone else need to be informed or involved, including the nominated safeguarding lead in your agency, before progressing to submitting a Safeguarding Concern?
- Are there any other internal policy or procedural requirements within your agency?
- If you unhappy about how your organisation is dealing with a Safeguarding Concern do you know how to escalate this, which could include the use of a Whistleblowing Policy?
Help to keep the adult safe until the Local Authority respond.
Professionals should read the London Multi-Agency Safeguarding Policy and Procedures (pages 61-66) for further information on this subject, using the checklists and good practice guidance that is provided.
5. Submit the Adult Safeguarding Concern
- Ensure all of the relevant fields in the Safeguarding Concern Form are fully completed with as much detail as possible, and submitted correctly using the contact details outlined in the link below. The Safeguarding Concern Form is also included on the weblink below.
- You should receive receipt of this and be kept informed of progress.
- If you do not receive any feedback on progress you should follow this up with the Local Authority involving your organisational lead if required.
- If the Safeguarding Concern does not progress and you feel the appropriate steps have not been taken to reduce or remove the risk to the adult, then you might consider challenging this decision. Read the Inter-Agency Escalation Policy July 2023 for further information.
This links to the subject of Professional Curiosity as it is good practice to respectfully challenge safeguarding decisions that you believe are not appropriate read more on Professional Curiosity.
6. Allegations against People in Positions of Trust (PiPOT)
The Local Authority’s 'relevant partners' (outlined in the Care Act), and those providing universal care and support services, should have clear policies for dealing with allegations against people who work, in either a paid or unpaid capacity, with adults with care and support needs.
Where such concerns are raised about someone who works with adults with care and support needs, it will be necessary for the employer (or student body or voluntary organisation) to assess any potential risk to adults with care and support needs who use their services, and, if necessary, to take action to safeguard those adults.
If the allegation and the circumstances of it matches the criteria outlined in this pathway, then the guidance for submitting a Safeguarding Concern to the Local Authority should be followed. The guidance for the Local Authority in conducting Safeguarding Enquiries (on the following pages) outline the possible outcomes that may be relevant in such cases.
Whilst the focus of safeguarding adults work is to safeguard one or more identified adults with care and support needs (adult at risk), there are occasions when incidents are reported that do not involve an adult at risk, but indicate, nevertheless, that a risk may be posed to adults at risk by a person in a position of trust.
- Examples of such concerns could include allegations that relate to a person who works with adults with care and support needs who has:
- Behaved in a way that has harmed, or may have harmed an adult or child (this could include their own family members).
- Possibly committed a criminal offence against, or related to, an adult or child.
- Behaved towards an adult or child in a way that indicates they may pose a risk of harm to adults with care and support needs.
When a person’s conduct towards an adult may impact on their suitability to work with or continue to work with children, this must be referred to the Local Authority’s Designated Officer (LADO).
Employers, student bodies and voluntary organisations should have clear procedures in place setting out the process, including timescales, for investigation and what support and advice will be available to individuals against whom allegations have been made. Any allegation against people who work with adults should be reported immediately to a senior manager within the organisation. Employers, student bodies and voluntary organisations should have their own sources of advice (including legal advice) in place for dealing with such concerns.
If an organisation removes an individual (paid worker or unpaid volunteer) from work with an adult with care and support needs (or would have, had the person not left first) because the person poses a risk of harm to adults, the organisation must make a referral to the Disclosure and Barring Service. It is an offence to fail to make a referral without good reason.
Disclosure and Barring Service (DBS) Briefing
In some instances a relevant agency may come across information about a person in a position of trust who does not work or volunteer for them, and feel it is appropriate to notify the local authority outside of the formal adult safeguarding procedures.
Decisions on sharing information must be justifiable and proportionate, based on the potential or actual harm to adults or children at risk and the rationale for decision-making should always be recorded.
LSAB Managing Allegations against People in Positions of Trust (PiPoT) Framework July 2024
Under the provisions of the Care Act 2014 Care and Support Statutory Guidance (Statutory Guidance) Lewisham Safeguarding Adults Board is required to have a Framework for how allegations involving People in Positions of Trust (PiPoT) working with adults with care and support needs should be notified and responded to.
This framework expands upon the outline provided in the Statutory Guidance and the Data Protection Act 2018 (UK General Data Protection Regulation – GDPR) to provide individual agencies with the information they need to be able to respond effectively to any PiPoT allegations or concerns.