Safeguarding adults policy template

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. 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).

(Tenant updates the angle-bracket placeholder.)

4. Types of abuse and the signs to look for

Staff are trained to recognise abuse and neglect and the signs that may indicate it. The Care Act 2014 recognises these categories. No list is exhaustive, and a person may experience more than one type.

• Physical abuse: hitting, rough handling, misuse of medication, inappropriate restraint. Possible signs: unexplained bruises, burns or fractures, fear of a particular person, flinching.
• Neglect and acts of omission: failing to provide food, warmth, medical care or support with daily living. Possible signs: poor hygiene, weight loss, untreated conditions, pressure sores, missed medicines.
• Psychological or emotional abuse: threats, humiliation, control, isolation. Possible signs: withdrawal, anxiety, fearfulness, change in behaviour.
• Financial or material abuse: theft, fraud, pressure over money or a will, misuse of property. Possible signs: unexplained loss of money, unpaid bills, missing belongings.
• Sexual abuse: any sexual act the person has not consented to, or cannot consent to. Possible signs: distress, injury, behaviour change, a sexually transmitted infection.
• Discriminatory abuse: abuse based on a protected characteristic, including harassment. Possible signs: the person being treated less favourably, excluded or insulted.
• Organisational or institutional abuse: poor care arising from the routines, systems or culture of a service. Possible signs: rigid routines, lack of choice or dignity, repeated low-level concerns.
• Modern slavery: slavery, human trafficking and forced labour. Possible signs: signs of control or fear, no personal effects or identity documents, not being allowed to speak alone.
• Domestic abuse: abuse by a partner, family member or carer, including coercive and controlling behaviour.
• Self-neglect: a person neglecting their own health, hygiene, or surroundings.

Staff report any concern that a person is being, or may be, harmed, whether or not it fits neatly into a category.

5. Preventing abuse

The Service actively prevents abuse, it does not only respond to it. Its preventative measures include:

• safer recruitment (see the recruitment policy): DBS checks at the right level, references, identity and right-to-work checks, completed before a person starts
• safeguarding training for all staff at the level their role requires, kept current and refreshed
• supervision, appraisal and an open culture in which staff can raise concerns without fear, supported by a clear whistleblowing route
• person-centred care planning that reduces the risk of neglect and institutional abuse
• meeting people's mental capacity and best-interests requirements so that any restriction is lawful and the least restrictive option
• learning from concerns, complaints and incidents to remove the causes of harm

6. The Service's approach to restraint

Restraint is any restriction of a person's movement or freedom against their will, or any use of force. It includes physical holds, medication used to control behaviour (chemical restraint), seclusion, and mechanical or environmental restriction. The Service:

• recognises restraint in all its forms, including subtle forms such as withholding a walking aid, over-using bed rails, or routinely locking a door
• uses restraint only where it is necessary to prevent harm, is a proportionate response to the likelihood and seriousness of that harm, and is the least restrictive option, and follows the Mental Capacity Act where the person lacks capacity to consent to it
• never uses restraint to punish, for staff convenience, or in place of adequate staffing or care planning
• records and reviews every use of restraint, raises it as a safeguarding concern, and notifies CQC where the threshold is met
• trains relevant staff in rights-respecting approaches (for example positive behaviour support and de-escalation), and uses physical-intervention techniques only from a recognised, certified training provider

7. 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.

(Tenant updates the named role-holders.)

8. Who to contact

The Service makes the reporting routes easy for everyone to find, at every level of the organisation:

• Safeguarding Lead: , .
• Deputy or out-of-hours contact: , , so a concern arising at any time can be raised straight away.
• Emergency: if a person is in immediate danger or a crime is in progress, call 999. For non-emergency police, call 101.
• Local Authority Safeguarding Team for the area where the Service operates: , <telephone, out-of-hours number, and referral portal>. For a child: the local authority children's services or MASH, .
• Care Quality Commission: for statutory notifications, per the statutory notifications policy.

(Tenant completes the named contacts, including the Local Authority Safeguarding Team for its own geographic area.)

A one-page reporting flow is displayed where staff can see it: recognise the concern, make the person safe (call 999 if urgent), tell the Safeguarding Lead the same working day, the Lead applies the threshold and refers to the Local Authority where it may be met, and CQC is notified where required.

9. 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 (see section 10). 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.

10. Allegations against a member of staff or management

Where a concern is an allegation against a member of staff, the response runs separately from the safeguarding response for the person, so neither prejudices the other.

• for an allegation involving a child, the Local Authority Designated Officer (LADO) is informed within one working day
• for an allegation involving an adult at risk, the equivalent adult-allegation route runs with the Local Authority
• an allegation against the Registered Manager or another manager is handled by someone who is not the subject and who is senior to or independent of them (the Nominated Individual, a director, or an external or independent person), so that the investigation is impartial. Where the Registered Manager and the Nominated Individual are the same person, the allegation is referred to the Local Authority, and the regulator where relevant, so that it is handled independently
• the Service informs the Local Authority and CQC as required, cooperates with any external investigation, and does not itself investigate a potential crime

11. Involving the person and their consent (Making Safeguarding Personal)

Safeguarding is done with the person, not to them. The Service:

• asks the adult at risk what they want to happen and the outcome they are seeking, and keeps them informed and involved throughout (the Making Safeguarding Personal approach)
• seeks the person's consent before sharing information or making a safeguarding referral, and respects their wishes, unless there is an overriding reason to act without consent: the person lacks the capacity to make that decision, other people (including children) are at risk, a serious crime may have been committed, or it is otherwise in the public interest
• where the person lacks capacity for the decision, acts in their best interests under the Mental Capacity Act and supports a referral for an independent advocate (an Independent Mental Capacity Advocate) where the person has no one else to represent them
• records the person's wishes, the consent decision, and the reasons where it acted without consent

12. 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.

13. 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.

14. 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.

15. Accessible information and specialist services

The Service makes this policy, and the way to raise a concern, accessible to everyone, including in easy-read or another format on request, so that people with a disability, impairment or sensory loss can use it. A service that specialises in the care of autistic people or people with a learning disability sets out how its staff are trained to communicate and work with them, and how its safeguarding arrangements meet their needs.

16. Related policies in this pack

• Safe Care and Treatment Policy
• Recruitment Policy
• Statutory Notifications Policy
• Mental Capacity Act and Capacity Policy

17. 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
• Care Act 2014, section 42 (https://www.legislation.gov.uk/ukpga/2014/23/section/42)
• Care and Support Statutory Guidance
• Local authority safeguarding adults procedures
• DBS barring referral guidance
• Care Quality Commission (Registration) Regulations 2009, Regulation 18 (notification of abuse)
• Working Together to Safeguard Children 2026 (where the service works with children)
• Mental Capacity Act 2005 (https://www.legislation.gov.uk/ukpga/2005/9)
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/13)

18. 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.

19. Document control

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.