Sample policy · Sexual health

Under-18s and safeguarding policy (sexual health)

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 11 (need for consent) for the assessment of competence and consent in young people. · primary source

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))

The regulation defines abuse to include:

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.

For a sexual health service, this duty sits alongside a young person's right to confidential care. A young person assessed as competent under the Fraser guidelines (for contraception and sexual health) or as Gillick competent can consent to that care, but the service stays alert to exploitation, abuse and coercion, and acts on any safeguarding concern.

3. Purpose

Young people have a right to confidential sexual health care, and that access protects their health. But a young person attending sexual health may also be at risk of exploitation or abuse, and the service may be the only place that risk is seen. This policy sets out how the Service provides confidential care to young people while recognising and acting on safeguarding concerns.

The Service must verify this policy against current GMC 0-18 guidance, the Fraser guidelines, and statutory safeguarding guidance before adoption.

4. Scope

This policy applies to:

5. Competence and confidential care

6. Recognising risk and exploitation

Every contact with a young person includes thinking about risk. The Service uses a recognised tool (such as the Spotting the Signs proforma) and is alert to indicators of child sexual exploitation, abuse or coercion, including:

7. Age thresholds

The Service confirms the current legal thresholds against the Sexual Offences Act and statutory guidance.

8. Acting on a concern

9. Recording

The competence assessment, the risk assessment (including the tool used), the decisions made, and any referral and its outcome are recorded clearly. The record shows that risk was actively considered, not just that care was given.

Operational controls to adapt

Roles and responsibilities

Under-18 consultation procedure

  1. Confirm age and identity. Record age, date of birth, who attended with the young person and any discrepancy or concern.
  2. Offer private time. The young person is seen alone for part of the consultation unless there is a recorded reason why this is not possible or safe.
  3. Assess competence. Record the Gillick or Fraser assessment, what the young person understood, and why confidential care is or is not appropriate.
  4. Screen for exploitation and coercion. Ask about partner age, power imbalance, pressure, gifts, drugs, alcohol, violence, trafficking, online abuse and whether anyone is controlling access to care.
  5. Apply age thresholds. Under-13 sexual activity is referred as a safeguarding matter. Ages 13 to 15 require documented risk assessment. Ages 16 to 17 still require vigilance for exploitation or abuse of trust.
  6. Decide on confidentiality limits. Explain what can stay confidential and what cannot. Record what is shared, with whom and why.
  7. Refer without delay where needed. Immediate danger is escalated to police or emergency services. Other safeguarding concerns follow local-authority and local safeguarding procedures.
  8. Track the outcome. Referrals are not left as "sent". The service records acknowledgement, outcome, safety plan and any follow-up action.

Records and register links

The under-18 safeguarding record should include:

Any missed under-18 risk assessment, delayed referral, unclear competence record, immediate danger, allegation of abuse, or repeated documentation gap is opened on the safeguarding or incident register and reviewed by governance.

10. Training

Everyone in the Service is trained in safeguarding children and adults to the level their role requires, in recognising exploitation, and in the referral routes, and is refreshed on the required cadence. A named safeguarding lead and deputy are in place. The Service records training and the next refresher dates.

11. Audit cadence

The Service checks, on a stated cadence, that:

The Registered Manager and the safeguarding lead review the results and record the improvement actions that follow.

12. 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.

Related reading

13. 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.

14. Document control

Version Date Author Changes
v1.1 2026-07-14 Verivius (sample) Added role ownership, under-18 consultation controls, safeguarding records, register links and related reading.
v1 2026-06-10 Verivius (sample) Conformed the existing draft to the Verivius policy standard: added the Reg 13 statutory anchor and verbatim quotes, plain-English summary, standard sources and advice blocks, and document control. All original sections and source URLs preserved.

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.

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.

A young person attending for contraception or a test may be the only person in the room who knows what is happening to them, and the service may be the only place the pattern is visible: a much older partner, gifts or substances tied to sex, or an adult who will not leave the room. Confidentiality and safeguarding are not opposites here. Confidential care is what keeps a 15-year-old coming back, and the record of competence, the exploitation screen and the reason a referral was or was not made is what turns a run of quiet attendances into something a colleague can act on. Without that trail, repeated infections, terminations or attendances are filed as episodes of care rather than read as a signal of coercion, because the clinician who sees the young person next is rarely the one who noticed the first sign. Inspection will test these records, but the reason to keep them properly is that a young person's safety depends on someone seeing the whole picture rather than one appointment at a time.

  1. A recognised exploitation tool (such as the Spotting the Signs proforma) is used at each under-18 contact and its indicators acted on, so the record shows risk was actively considered, not just that care was given. Contraception or testing provided with no exploitation screen behind it leaves the young person who is being exploited as the one who loses.

    Strong evidence: Section 6 (a recognised tool, alert to child sexual exploitation, abuse or coercion); section 9 (the record shows that risk was actively considered, not just that care was given); the records field for the exploitation and coercion screen; and the audit-cadence check that the recognised exploitation tool was used and indicators acted on.

    Weak evidence: The Spotting the Signs proforma sits on the shared drive, but the note for an under-18 attendance reads only "sexual health advice given, contraception issued". Where the tool is used it is completed once at registration and never again, or every box is ticked "no concerns" while partner age and the question about who controls access to care are left blank. Repeating the screen at every contact rather than once per patient is a Verivius default, not a professional requirement.

    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.

  2. Age thresholds are applied correctly: every disclosure of sexual activity by a child under 13 is referred as a safeguarding matter, and activity at ages 13 to 15 is risk-assessed for abuse, exploitation or coercion. An under-13 disclosure that is not referred sends the child back to the same situation with nothing changed.

    Strong evidence: Section 7 and procedure step 5 (under-13 sexual activity is referred as a safeguarding matter; ages 13 to 15 require a documented risk assessment); the records field for the safeguarding threshold applied; and the audit-cadence check that age thresholds were applied correctly, with under-13 disclosures referred.

    Weak evidence: The record captures the young person's age but never the partner's, so nobody can show the 13 to 15 risk assessment actually happened or what the power imbalance looked like. Under-13 disclosures are rare enough that the team relies on the memory of whoever was on shift, with no documented threshold decision and no way to show the referral was made rather than intended. The under-13 position is statute; the expectation that a 13 to 15 assessment is written down comes from safeguarding guidance and this policy, not from the face of the Act.

    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.

  3. A Fraser or Gillick competence assessment is recorded for each under-18, showing what the young person understood and why confidential care was or was not appropriate, not just that care was given. Confidential care given with no competence record leaves the next clinician unable to tell what the young person actually understood.

    Strong evidence: Procedure step 3 (record the Gillick or Fraser assessment, what the young person understood, and why confidential care is or is not appropriate) and the records field for the competence assessment, Fraser or Gillick rationale and consent decision; the audit-cadence check that competence and risk were assessed and recorded for under-18 attendances.

    Weak evidence: The entry says "Fraser competent" or "Gillick assessed" and nothing sits behind it: no note of what the young person understood about the treatment, the risks, or the consequences of not involving a parent, and no reason recorded for why confidential care was appropriate. Competence assessed once at a first visit is carried forward to later visits and different decisions without being revisited. Without that assessment the service cannot show consent was validly obtained at all, which is where a documentation gap becomes a consent problem.

    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.

  4. A safeguarding concern is referred promptly to local-authority children's social care, or to the police where a child is in immediate danger, whether the episode is NHS-commissioned or private-pay, and where no referral is made the reason is recorded. A concern with neither a referral nor a recorded reason for not referring cannot be told apart, later, from a concern nobody ever noticed.

    Strong evidence: Section 8 (shared with the safeguarding lead and referred to children's social care, or the police where a child is in immediate danger, with the reason recorded); the records field for the referral decision and reason if no referral was made; and the audit-cadence check that safeguarding concerns were referred promptly under local procedures.

    Weak evidence: The clinician escalated verbally to the safeguarding lead and the trail stops there, with no record of who decided, when, or against which threshold. Where no referral was made the notes are simply silent, which on paper cannot be told apart from the concern never having been considered. Watch too for a statutory notification to CQC under the Care Quality Commission (Registration) Regulations 2009 logged as though it discharged the referral to local-authority children's social care. They are separate duties owed to different bodies, and making one does not satisfy the other; the referral to children's social care still has to be made and recorded in its own right.

    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.

  5. Referrals are followed through to acknowledgement, outcome, safety plan and follow-up, not left as 'sent'. A referral fired off with no record of what happened next tells the next clinician nothing about who is holding the case.

    Strong evidence: Procedure step 8 (referrals are not left as 'sent'; the service records acknowledgement, outcome, safety plan and any follow-up) and the records field for the referral date, destination, named contact, acknowledgement, outcome and follow-up.

    Weak evidence: The safeguarding log holds a referral date and a destination and nothing else: no named contact, no acknowledgement, and no answer to whether children's social care accepted or declined it. If the young person attends again, the team cannot say what the safety plan was or who is holding the case, so the second attendance starts from scratch and the pattern that made the first referral necessary stays invisible.

    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.

  6. The young person is offered private time and seen alone for part of the consultation unless there is a recorded reason why not, so a controlling adult cannot mask risk. A whole consultation conducted with an accompanying adult present, and no record of why, is the one in which a young person being controlled has no moment to say so.

    Strong evidence: Procedure step 2 (the young person is seen alone for part of the consultation unless there is a recorded reason why this is not possible or safe) and the records field for whether the young person was seen alone.

    Weak evidence: The consultation record shows that a parent, partner or older friend attended but is silent on whether the young person ever had time alone. Reception has no discreet way to separate the two, so "they did not want to be seen alone" is assumed on the young person's behalf rather than asked and recorded, and the accompanying adult stays in the room throughout, including for the exploitation questions.

    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.

Related

Last verified 20 July 2026

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Last reviewed 10 June 2026