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Independent Safeguarding Submission Form – Haus of Ästhetik Ltd

Purpose:

This form provides a confidential and independent channel for reporting any safeguarding concern involving patients, staff, or persons in a position of trust (PIPOT). It is reviewed directly by the Governance & Assurance Officer (GAO) to ensure impartiality and compliance with CQC Regulation 13 and local authority safeguarding procedures.


Oversight:

All submissions bypass the clinic’s DSL where necessary and are reviewed independently by the GAO. Concerns meeting threshold are referred externally within one working day to LADO, DSCP/DSAB, Police, or CQC.

Reporting Member

Would you like your identity to remain confidential?
Yes
No
Anonymous Submission
Multi-line address

Incident Form

Section 2 – Person at Risk

Date Of Birth If Known
Day
Month
Year
Relationship to Clinic:
Is the person under 18 years old?

If under 18:

Type of Incident
Gillick Competence considered?
Yes
No
Not Applicable
Parent/Guardian aware?
Yes
No
Not Safe To Inform

Section 3 – Nature of Concern

(tick all that apply; required under DSCP thresholding)

Instructions for Incident Description: Provide a clear, factual account of the incident. Include what happened, where, when, and who was involved. Describe any contributing factors or sequence of events. Avoid opinions or assumptions, stick to what was observed or known.

Action Taken At The Time:
Follow-Up Action /
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