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
- Children Act 1989, section 47: https://www.legislation.gov.uk/ukpga/1989/41/section/47
- Care Act 2014, section 42: https://www.legislation.gov.uk/ukpga/2014/23/section/42
- Female Genital Mutilation Act 2003, section 5B: https://www.legislation.gov.uk/ukpga/2003/31/section/5B
- GOV.UK, multi-agency statutory guidance on female genital mutilation: https://www.gov.uk/government/publications/multi-agency-statutory-guidance-on-female-genital-mutilation
- Counter-Terrorism and Security Act 2015, section 26: https://www.legislation.gov.uk/ukpga/2015/6/section/26
- GOV.UK, Prevent duty guidance: https://www.gov.uk/government/collections/prevent-duty-guidance
- GOV.UK, Working Together to Safeguard Children: https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
- GOV.UK, Domestic Abuse Act 2021 statutory guidance: https://www.gov.uk/government/publications/domestic-abuse-act-2021-statutory-guidance
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 13: https://www.legislation.gov.uk/uksi/2014/2936/regulation/13
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 18: https://www.legislation.gov.uk/uksi/2014/2936/regulation/18
5. Scope
This policy applies to:
- child safeguarding concerns raised during consultation or patient contact
- adult-at-risk concerns raised during consultation or patient contact
- domestic abuse disclosures
- FGM concerns and mandatory-reporting cases
- Prevent concerns
- safeguarding concerns involving staff, locums, contractors or visiting professionals
- face-to-face, telephone, video and online consultations
- reception, administration and clinical contact
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:
- make the child safe where immediate action is needed
- listen and record the child's words as closely as possible
- record clinical facts and observations
- avoid promising confidentiality
- inform the safeguarding lead or senior clinician
- follow the local Multi-Agency Safeguarding Hub (MASH) or children's safeguarding route
- call emergency services where there is immediate danger
- consider whether other children may be at risk
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:
- make the person safe where immediate action is needed
- assess capacity and consent where relevant
- record the person's words and staff observations
- inform the safeguarding lead or senior clinician
- follow the local authority adult safeguarding route where the threshold appears met
- consider advocacy or IMCA where relevant
- consider whether children or other adults may also be at risk
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:
- speak to the patient alone where safe
- do not confront the alleged perpetrator
- record the patient's words as closely as possible
- check immediate safety
- follow the local domestic abuse route
- use the local IRIS pathway where commissioned
- consider MARAC referral according to local threshold
- consider child safeguarding where children are exposed to domestic abuse
- call emergency services where there is immediate danger
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:
- make the child safe
- inform the safeguarding lead or senior clinician
- follow the police mandatory-reporting route
- follow local child safeguarding procedures
- record the report and reference number
- consider whether siblings or other children may be at risk
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:
- make the person safe where immediate action is needed
- record facts, words used and context
- inform the safeguarding lead or senior clinician
- follow the local Prevent referral pathway
- consider child or adult safeguarding where relevant
- call emergency services where there is immediate danger
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:
- create an opportunity to speak to the patient alone where safe
- use professional interpreting where needed
- avoid using family members as interpreters for safeguarding concerns
- record the patient's words and relevant clinical observations
- explain information-sharing limits
- escalate immediately where there is immediate risk
- preserve records where the concern may involve crime, abuse or professional misconduct
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:
- makes the patient safe
- preserves records, rotas, messages and electronic audit trails
- removes the person from contact where needed
- follows the local authority staff-allegation process
- contacts the Local Authority Designated Officer where the allegation concerns a child
- follows adult safeguarding or Person in a Position of Trust route where the allegation concerns an adult at risk
- considers police referral where a crime may have been committed
- considers professional regulator referral, DBS referral, CQC notification and employment action
No staff member investigates an allegation about themselves.
9. Responsibilities
- Registered Manager: owns this policy, ensures safeguarding governance and signs off annual review.
- Safeguarding lead: owns day-to-day safeguarding process, local referral routes, training oversight and record review.
- Lead GP or GP Partner: reviews doctor-only clinical judgement, complex disclosure and medical-record safeguarding decisions.
- Practice Manager: maintains local contact sheets, staff training records and governance reporting.
- All staff: recognise concerns, record facts, take immediate safety action and report through the Practice pathway.
10. Recording requirements
The Practice keeps the following records:
- safeguarding concern record
- patient words where relevant
- clinical observations
- capacity and consent considerations where relevant
- referral decision
- referral form or reference number
- police or Prevent report reference where relevant
- domestic abuse or MARAC action where relevant
- staff allegation record
- CQC notification decision
- learning and improvement action
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:
- Monthly: the safeguarding lead reviews open safeguarding actions and urgent route changes.
- Quarterly: the Practice reviews safeguarding themes, FGM and Prevent pathway checks, staff training and referral quality.
- Annually: the Registered Manager audits this policy against local safeguarding procedures, CQC source material and statutory source material.
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:
- policy owner
- version number
- date approved
- next review date
- changes made since the last version
- source material checked during the review
13. Related records
- Safeguarding concern register
- Incident register
- Staff training matrix
- Local safeguarding contact sheet
- Domestic abuse pathway
- FGM reporting record
- Prevent referral record
- Staff allegation record
- CQC notification record
- Improvement action register
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.
- CQC Regulation 13: Safeguarding service users from abuse and improper treatment
- CQC Regulation 18: Staffing
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/13)
- Children Act 1989 and Children Act 2004
- Working Together to Safeguard Children 2026
- Keeping Children Safe in Education 2025 (where education-adjacent)
- Local Safeguarding Children Partnership procedures
- Local Authority Designated Officer (LADO) procedures
- NSPCC safeguarding guidance
- Care Act 2014, section 42; local authority safeguarding adults procedures; Care and Support Statutory Guidance
- Mental Capacity Act 2005; MCA Code of Practice (2007, update in consultation); Human Rights Act 1998 (Article 5 ECHR)
- Female Genital Mutilation Act 2003 and the multi-agency statutory guidance on female genital mutilation
- Counter-Terrorism and Security Act 2015 (section 26) and the Prevent duty guidance
- Domestic Abuse Act 2021 statutory guidance; local IRIS and MARAC pathways
- DBS barring referral guidance
- CQC assessment framework and sector-specific guidance, as updated by CQC from time to time
- CQC Fundamental Standards
On deprivation of liberty: the Supreme Court judgment in AGNI (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 give valid consent to confinement for Article 5 purposes. CQC's statement of 8 June 2026 confirms immediate effect, that providers may need legal advice pending official guidance, and that the Mental Capacity Act 2005 and Regulation 11 (consent) requirements are unchanged. DHSC guidance on Deprivation of Liberty Safeguards (DoLS) and Court of Protection cases is awaited. This change does not alter how the Practice assesses capacity or consent under the Mental Capacity Act or Regulation 11; those requirements are unchanged.
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 | 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 tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.