Sample policy · GP

Safeguarding policy (primary care) (gp)

Statutory anchor: Regulation 13 (safeguarding service users from abuse and improper treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 18 (staffing) and non-CQC primary legislation named in the sources below: Children Act 1989 (section 47), Care Act 2014 (section 42), Female Genital Mutilation Act 2003 (section 5B), and the Counter-Terrorism and Security Act 2015 (section 26, the Prevent duty).

1. What the regulation says

Service users must be protected from abuse and improper treatment in accordance with this regulation. (Reg 13(1) (the headline duty))

Systems and processes must be established and operated effectively to prevent abuse of service users. (Reg 13(2) (prevention systems))

Systems and processes must be established and operated effectively to investigate, immediately upon becoming aware of, any allegation or evidence of such abuse. (Reg 13(3) (investigation systems))

A service user must not be deprived of their liberty for the purpose of receiving care or treatment without lawful authority. (Reg 13(5) (lawful authority for deprivation of liberty))

any behaviour towards a service user that is an offence under the Sexual Offences Act 2003, (Reg 13(6)(a) (sexual offences))

ill-treatment (whether of a physical or psychological nature) of a service user, (Reg 13(6)(b) (ill-treatment))

theft, misuse or misappropriation of money or property belonging to a service user, or (Reg 13(6)(c) (theft / misuse / misappropriation))

neglect of a service user. (Reg 13(6)(d) (neglect))

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/13. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Service users must be protected from abuse and improper treatment. You need effective systems to prevent abuse, and effective systems to investigate any allegation or evidence of abuse as soon as you become aware of it. Care must not be provided in a way that discriminates, uses disproportionate control or restraint, is degrading, or significantly disregards the service user's needs. Service users cannot be deprived of their liberty without lawful authority.

3. Purpose

This policy sets out how the Practice identifies, records and responds to safeguarding concerns in primary-care consultations and patient contact.

It covers child safeguarding, adults at risk, domestic abuse, FGM mandatory reporting, Prevent concerns, staff allegations and learning.

4. Sources to verify before adoption

5. Scope

This policy applies to:

The Practice does not use this policy in place of local safeguarding children, adult safeguarding, domestic abuse, FGM or Prevent pathways.

6. Safeguarding pathways

Staff follow the correct pathway for the concern identified.

6.1 Child safeguarding disclosure

Where a child safeguarding concern is identified, staff:

The Practice verifies referral thresholds and forms against the current local safeguarding children partnership procedure.

6.2 Adult-at-risk disclosure

Where an adult-at-risk concern is identified, staff:

The Practice verifies the current local authority adult safeguarding procedure before adoption.

6.3 Domestic abuse and IRIS or MARAC pathway

Where a patient discloses domestic abuse or staff suspect domestic abuse, staff:

The Practice keeps local IRIS, domestic abuse and MARAC contacts with this policy where they apply.

6.4 FGM mandatory reporting

The Practice treats FGM concerns as safeguarding concerns and follows the current FGM Act 2003, statutory guidance and local safeguarding route.

For section 5B, the exact statutory phrases "in England and Wales", "girl who is aged under 18", "chief officer of police" and "before the end of one month" are load-bearing. Staff check the current legislation.gov.uk text before making or recording a mandatory report.

Where staff identify a known case that appears to meet the mandatory-reporting duty, staff:

The Practice does not paraphrase the statutory duty in local training. Training material cites the current FGM Act 2003 section 5B source.

6.5 Prevent concern

Where staff identify a Prevent or radicalisation concern, staff:

The Practice verifies local Prevent contacts and thresholds before adoption.

7. Consultation privacy and disclosure handling

Primary care often identifies safeguarding concerns during private consultation.

Staff:

Staff do not investigate safeguarding concerns themselves. They record, report and follow the correct pathway.

8. Staff allegations and escalation

Where a safeguarding allegation involves staff, locums, contractors or visiting professionals, the Registered Manager:

No staff member investigates an allegation about themselves.

9. Responsibilities

10. Recording requirements

Each safeguarding concern is entered in the access-controlled safeguarding record without delay. The record should include:

Records are factual, contemporaneous and access-controlled.

11. Audit cadence

The Practice uses the following Verivius default audit rhythm unless current source material requires more frequent review:

Audit findings are recorded as improvement actions with an owner and review date.

12. Version control and review date

The Practice keeps a controlled copy of this policy. The footer or document-control table records:

13. Related policies and records

This policy should be read with:

The supporting records are:

Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.

14. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

On deprivation of liberty: the Supreme Court judgment of 2 June 2026 overruled the previous "acid test". Deprivation of liberty is now determined by a multifactorial assessment, and a person who lacks capacity under the Mental Capacity Act may still be able to give valid consent to confinement for Article 5 purposes. CQC confirms immediate effect and that the Mental Capacity Act 2005 and Regulation 11 consent requirements are unchanged. DHSC's guidance published on 15 June 2026 sets out the factors providers should consider and advises referral where there is doubt. The republished DoLS Code of Practice does not fully reflect the 2026 judgment. This change does not alter how the Practice assesses capacity or consent under the Mental Capacity Act or Regulation 11.

15. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

16. Document control

Version Date Author Changes
v1.2 2026-07-21 Verivius (sample) Added a decision-ready safeguarding record and linked the primary-care pathway to its companion policies.
v1.1 2026-07-21 Verivius (sample) Replaced the pending-guidance wording with current DHSC guidance on the 2026 Supreme Court judgment.
v1 2026-06-10 Verivius (sample) Initial sample template, conformed to the Verivius policy standard.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

In general practice a safeguarding concern rarely arrives whole. It shows up as a child who has missed two appointments, an older person whose relative answers every question for them, an injury that does not fit the account given, or a patient who books the last slot of the day because that is the only time they can come alone. The person causing the harm is often sitting in the consulting room, so a private moment and a professional interpreter rather than a family member are the most protective things a practice can offer, and the patient's own words written at the time are frequently the only durable trace of a disclosure that is never repeated. That record is what allows a Multi-Agency Safeguarding Hub or a local authority adult safeguarding team to see a pattern no single practice contact would reveal, and what lets the next clinician pick the concern up when the patient returns. Practices that do this well keep the referral decision, the Care Quality Commission notification decision and any staff-allegation route as three separate judgements, each written down when it was made, because reconstructing them months later serves nobody, least of all the patient.

  1. A safeguarding concern reaches the safeguarding lead and then goes on to the correct statutory pathway: the local Multi-Agency Safeguarding Hub (MASH) or children's route where the concern is about a child, or the local authority adult route where the Care Act 2014 section 42 threshold appears met. Staff record and report rather than investigating it themselves, because the person at risk needs the agency holding the statutory powers to see the concern, not a version of it worked out inside the Practice. The failure that leaves someone unprotected is a disclosure handled inside the Practice, where a threshold judgement was made but the concern was never referred on.

    Strong evidence: The safeguarding concern record with the referral decision and the referral form or reference number (section 10), verified against the current local safeguarding children partnership and local authority adult safeguarding procedures (sections 6.1 and 6.2).

    Weak evidence: A consultation entry that reads "safeguarding concern, discussed with safeguarding lead" and then stops, with no referral decision, no referral form and no reference number anywhere in the record. Or a threshold judgement recorded as a bare opinion such as "did not meet threshold", with nothing to show which current local safeguarding children partnership or local authority adult safeguarding procedure was applied, by whom, or on what date.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  2. The record shows a CQC notification decision taken on the abuse allegation itself. A safeguarding referral to the local authority and a statutory notification to CQC under the Care Quality Commission (Registration) Regulations 2009 are separate duties owed to different bodies, and making one does not discharge the other. What goes wrong is a Practice that treats the MASH or local-authority referral as having covered the CQC duty and records no separate notification decision, so nobody outside the local authority ever learns of the allegation.

    Strong evidence: The CQC notification decision held in the safeguarding concern record and the separate CQC notification record (section 10 and related records).

    Weak evidence: A safeguarding register with a column for the local authority referral reference and no column at all for the notification decision, so the two duties are never visibly separate. Or a record where the referral reference is present and the notification field is blank, marked "N/A", or filled in only once someone asked, on the assumption that the local authority would tell the regulator.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Care Quality Commission (Registration) Regulations 2009, reg 18(2)(e)

  3. An allegation against a staff member, locum, contractor or visiting professional goes down the Registered Manager route: records, rotas, messages and electronic audit trails preserved, the person removed from contact where needed, and the Local Authority Designated Officer (LADO) contacted where the allegation concerns a child. Nobody investigates an allegation about themselves, because the patient's account has to survive contact with the person it concerns. The failures are an allegation handled by the person it concerns, or evidence that was never pulled at the time and can no longer be retrieved.

    Strong evidence: The staff allegation record showing preserved records and audit trails, the LADO or adult Person in a Position of Trust referral, and the separately recorded decisions on police referral, professional regulator referral, Disclosure and Barring Service (DBS) barring referral and statutory notification to CQC, each considered on its own footing (section 8).

    Weak evidence: An allegation record that starts only after the manager has already asked the person to explain themselves, with the manager's summary of that conversation standing as the account. Or rotas, messages and clinical-system audit trails that were never pulled at the time and can no longer be retrieved, closed off with a line such as "resolved locally, no further action" that does not show whether the Local Authority Designated Officer, police, professional regulator and Disclosure and Barring Service routes were considered and why each was ruled out.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  4. Staff apply the Female Genital Mutilation Act 2003 section 5B mandatory-reporting duty from the current statutory wording rather than a local paraphrase, and record the police report and its reference. In England and Wales the duty falls personally on the regulated professional who was told by the girl herself or who saw the physical signs, and passing the case to the safeguarding lead does not discharge it. The failures that leave a girl who is aged under 18 unprotected are a known case never reported to the police, and training material that paraphrases the load-bearing statutory phrases so that nobody can tell what actually triggers the duty.

    Strong evidence: The FGM reporting record with the report reference (sections 6.4 and 10); the policy requires staff to check the current legislation.gov.uk section 5B text (phrases such as 'girl who is aged under 18' and 'before the end of one month') before making or recording a report.

    Weak evidence: A training slide or crib sheet telling staff to "report female genital mutilation (FGM) to the police within a month", from which nobody can tell whether the duty bites on suspicion or only where the professional was told by the girl herself or saw the physical signs, in a girl who is aged under 18. Or an FGM record that names the safeguarding lead the case was passed to and stops there, with no police report reference, when the duty falls personally on the regulated professional who was told or who saw the signs and is not discharged by handing the case on.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Female Genital Mutilation Act 2003, s.5B (inserted by Serious Crime Act 2015 s.74)

  5. Disclosures are recorded factually and contemporaneously in the patient's own words, with an opportunity created to speak to the patient alone, professional interpreting used rather than a family member, and records preserved where a crime or abuse may be involved. The patient's own sentence is the thing the next clinician needs, and the relative offering to interpret may be the person the patient is frightened of. What goes wrong is a disclosure summarised second-hand or interpreted by a relative, or records not preserved.

    Strong evidence: The safeguarding concern record capturing the patient's words, clinical observations and capacity and consent considerations, kept factual, contemporaneous and access-controlled (sections 7 and 10).

    Weak evidence: A disclosure written up as the clinician's paraphrase, "patient reports ongoing issues at home", when the patient's own sentence was the thing worth keeping. Or a note showing that a partner or adult child interpreted, or that the whole consultation took place with the accompanying person in the room, with nothing to show anyone tried to create a private moment.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

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Last verified 20 July 2026

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Last reviewed 21 July 2026