Standards › Standard 2E › Policies
Policy · WRK-POL-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2E.10
At a glance
- Any staff member can report a safety concern, misconduct or wrongdoing through a route that bypasses their line manager.
- Reports can be made in writing, by phone or in person, and can be anonymous.
- No one who speaks up is treated unfairly for doing so.
- Every report is acknowledged and followed up, and the reporter is told the outcome.
- Stop and get help straight away if: a staff member raises a safety concern and cannot find a route that bypasses their manager, or a retaliation complaint is not investigated.
1. Purpose
To make sure staff can raise safety concerns, misconduct and wrongdoing safely, without going through the person they are concerned about [EC].
2. Scope
| Applies to | All workforce members, locums, volunteers and students on placement |
| Locations | All services and outreach work |
| When | Always; from the moment a concern is noticed |
| Does not apply to | Routine workplace issues, which follow WRK-SOP-005 |
3. Definitions
| Term | Meaning |
|---|---|
| Speak-up | Raising a concern about safety, misconduct or wrongdoing through a defined route |
| Detriment | Any unfair treatment because a person raised a concern |
| Speak-up lead | A named senior person, independent of line management, who receives and oversees reports |
4. Background
Staff are often the first to see a danger. Where they cannot speak up safely, harm is hidden. This is a non-negotiable criterion because harm can continue while a concern is ignored.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Chief executive | Accountable for the speak-up route and its protection | Executive |
| Speak-up lead | Receives reports, acknowledges them and oversees investigation | Trained in investigation and confidentiality |
| Line managers | Do not stop or discourage a report, and pass on concerns they receive | Management |
| All staff | Speak up when they see a risk | Own role |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Speak-up contact details | Current, displayed in every staff area | Checked monthly |
7. Safety
- Concerns about immediate danger to patients are acted on at once. The reporter does not need to be certain, only concerned.
8. Before you start
- Confirm the speak-up lead, and at least one external route, are named and reachable.
9. Procedure
Step 1. Make the report.
- Use any route: the speak-up lead, a named senior contact outside the line, or an external route.
- Anonymous reports are accepted.
Key point: The route bypasses the line manager. That is the point.
Step 2. Acknowledge.
- Acknowledge the report within 3 working days, if the reporter gave contact details.
Key point: Acknowledgement shows the report was received.
Step 3. Investigate.
- Investigate by someone independent of the issue.
- Protect the reporter’s identity as far as possible.
Key point: Investigation starts within 10 working days.
Step 4. Feed back and protect.
- Tell the reporter the outcome and what has changed, as far as the law allows.
- Check for any detriment at 3 and 6 months.
Key point: Protection is checked, not assumed.
10. Decision points
- If a report shows immediate danger to patients, the chief executive acts the same day, without waiting for the full investigation.
11. Special situations
| Situation | Action |
|---|---|
| Concern about the speak-up lead | Report to the chief executive or to the board chair, who appoints an independent person. |
| Report to an external regulator | Permitted at any time. The organisation does not obstruct it. |
12. Escalation
- Any report of detriment, or any report not acknowledged within 3 working days, is reported to the chief executive the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Reports acknowledged within 3 working days | 100% | Quarterly | Speak-up lead | Escalate to chief executive |
| Investigations started within 10 working days | 100% | Quarterly | Speak-up lead | Escalate to chief executive |
| Staff who know the route (survey or spot check) | At least 70% | Yearly | Human resources lead | Re-publish the route and train |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Speak-up report log | Confidential speak-up files | Employment plus 6 years |
15. Training
- All staff are told about the route at induction and at each annual refresher. Managers are trained to receive and pass on concerns.
16. Related documents
| ID | Title | Use |
|---|---|---|
| WRK-SOP-010 | Concern handling and protection from retaliation | How reports are handled and protected |
| WRK-SOP-005 | Staff grievance and investigation procedure | Routine workplace issues |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. Route design to be reviewed by the Committee. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)