Safeguarding from abuse policy (Reg 13)

1. What the regulation says

Systems and processes must be established and operated effectively to prevent abuse of service users.

Systems and processes must be established and operated effectively to investigate, immediately upon becoming aware of, any allegation or evidence of such abuse.

any behaviour towards a service user that is an offence under the Sexual Offences Act 2003 … ill-treatment (whether of a physical or psychological nature) … theft, misuse or misappropriation of money or property … neglect of a service user.

A service user must not be deprived of their liberty for the purpose of receiving care or treatment without lawful authority.

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 British 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. Reg 13 sits alongside Section 42 of the Care Act 2014 (local-authority safeguarding enquiry duty for adults at risk), Working Together to Safeguard Children for children, and the LADO process for allegations against staff working with children.

3. Scope

This policy applies to all employees, contractors, volunteers, and external parties who interact with service users at any location operated by . It covers safeguarding of adults at risk under the Care Act 2014, safeguarding of children under the Children Acts 1989 and 2004, and the staff-allegation routes (LADO for children, the equivalent adult-allegation process for adults).

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4. Roles and responsibilities

• Registered Manager: accountable for the safeguarding response under Reg 13. Reviews every safeguarding concern at closure, signs off the threshold reasoning where the concern was not referred to the local authority, and reviews aggregate safeguarding patterns at the monthly governance meeting.
• Nominated Individual: holds provider-side accountability for safeguarding across all locations.
• Safeguarding Lead (named individual): the day-to-day safeguarding-decision authority. Receives raised concerns, decides the threshold call, runs the local-authority referral where required, tracks the LA outcome to closure. Holds the relevant safeguarding training at level 3 minimum.
• Children's Safeguarding Lead (named individual, where relevant): for services that work with children, the named lead for child-safeguarding referrals through the local Multi-Agency Safeguarding Hub (MASH). Holds the relevant training to the level the role requires.
• All staff: recognise the signs of abuse, neglect, and improper treatment; raise concerns to the Safeguarding Lead immediately; record what they saw or heard accurately in the safeguarding-concerns register; do not investigate themselves.

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5. Procedure

The safeguarding-response procedure operationalises Reg 13 across the lifecycle from first awareness to closure.

1. Recognise and report. Any team member who suspects abuse, neglect, or improper treatment, or any deprivation of liberty without lawful authority, raises the concern to the Safeguarding Lead the same working day. Where the harm is immediate, the team member ensures the person is safe before raising. Police are called immediately if a crime is in progress.
2. Log the concern. The Safeguarding Lead opens a safeguarding-concerns record the same working day. The record captures the subject (without identifying patient detail in the summary field where it can be avoided), the category (physical, neglect, financial, sexual, psychological, discriminatory, organisational, modern slavery, domestic, self-neglect), the source of the concern (witnessed, reported by the person, reported by a family member, reported by a colleague), and the initial threshold reasoning.
3. Threshold call. The Safeguarding Lead applies the Section 42 threshold for adults (or the child-safeguarding threshold for children) within 24 hours. The reasoning is recorded against the concern record, not in the Safeguarding Lead's head.
4. Refer where required. Where the threshold may be met, the Safeguarding Lead submits a referral through the local authority's safeguarding channel (LA portal, MASH form, or duty officer call, depending on the area). The referral submission is recorded with channel, submitter, timestamp, and any reference number the LA returns.
5. Staff-allegation fork (where relevant). Where the concern involves an allegation against a staff member, a parallel staff-allegation case opens with cross-link preserved. For allegations involving children, the LADO is informed within 24 hours. For allegations involving adults, the equivalent adult-allegation route runs. The two response tracks (safeguarding concern about the service user; allegation about the staff member) operate independently.
6. CQC notification check. Reg 18 of the Registration Regulations 2009 requires notification of any allegation of abuse to CQC. The Safeguarding Lead spawns a statutory notification record where the threshold is met, per the CQC statutory notifications policy.
7. Track outcomes. The local-authority response (no further action, s42 enquiry opened, joint investigation, safeguarding plan) is recorded against the concern when it arrives. The concern stays open in the register until the LA outcome is captured.
8. Closure with reasoning. Closure happens when the LA outcome is known and any provider-side actions have been completed. The closure paragraph records what was found, what was done, and what changed at the provider as a result.
9. Improvement actions. Where the concern surfaces a change-to-practice requirement, one or more improvement actions are opened and cross-linked to the concern. The actions run through the standard improvement-actions lifecycle.
10. Aggregate pattern review. Quarterly safeguarding-pattern review at the governance meeting. The Safeguarding Lead presents the trailing-12-month picture (referral count, outcome mix, theme tagging, time-to-referral) and the leadership team agrees any system-level action.

6. Training requirement

All staff complete safeguarding training to the level the role requires (Adult Safeguarding Level 1 minimum for any role; Level 2 for clinical and direct-care staff; Level 3 for the Safeguarding Lead and any team member regularly making referral-threshold judgements; Level 4 for the named safeguarding lead in services involving complex multi-agency casework). For services working with children, Child Safeguarding Level 1, 2, or 3 applies per the same role-level pattern.

Refresher cadence: every three years minimum for Levels 1 and 2; annually for Level 3 and Level 4.

The Mental Capacity Act 2005 awareness training (minimum Level 1) is also required for any staff likely to encounter incapacitated adults; the Deprivation of Liberty Safeguards element is required for any staff in adult social care or service-user-restriction roles.

Training records are held in the tenant's training matrix register and surfaced on the assurance calendar.

7. Audit

Compliance with this policy is monitored by the Registered Manager and Safeguarding Lead jointly:

• Quarterly file audit: every safeguarding concern closed in the trailing 12 months is reviewed for completeness of threshold reasoning, evidence of LA referral where it should have happened, capture of the LA outcome, and closure quality.
• Quarterly pattern review: aggregate concern themes by location, by category, by staff team, and by source. Patterns producing more than three concerns in a quarter are reviewed for system-level cause.
• Annual policy review: the policy itself is re-read against the live Reg 13 text, Care Act 2014 s42 guidance, and the local authority's current safeguarding referral guidance.
• Training-currency dashboard: the safeguarding-training percentage current is reviewed monthly at the leadership meeting.

Audit findings are recorded in the tenant's audit register and presented at the monthly governance meeting; any actions are logged in the improvement-actions register.

8. Record-keeping

Safeguarding records (concerns, referral records, LA outcome letters, staff-allegation case files, statutory notification records spawned from safeguarding) are held in the tenant's safeguarding system for a minimum of 8 years from the date of the last entry, aligned to the NHS Code of Practice on Records Management. Records relating to children's safeguarding concerns are retained until the child reaches the age of 25 (or longer where the matter is the subject of legal proceedings), per Working Together guidance.

Staff-allegation case files are retained until the staff member retires or for the equivalent period above, whichever is the longer, given the potential need to reference the file in a future fit-and-proper-persons check.

The Verivius platform records the per-record audit trail indefinitely while the workspace is active.

9. Related policies in this pack

• Person-Centred Care Policy (hscra-reg-9-person-centred-care)
• Safe Care and Treatment Policy (hscra-reg-12-safe-care-and-treatment)
• Fit and Proper Persons (Staff) Policy (hscra-reg-19-fit-and-proper-persons-employed)
• Statutory Notifications Policy (cqc-reg-18-notification-of-other-incidents)
• Mental Capacity Act and Capacity Policy (mca-2005-capacity-and-consent)

10. Document control

This sample policy template was issued by Verivius as part of the Mock Inspection design partner onboarding pack. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and the live regulation diverge, the live regulation wins.