Standards › Standard 2E › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · WRK-SOP-010 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2E.10
At a glance
- Handle every speak-up report under WRK-POL-005.
- Protect the reporter from any detriment, and record every protection step.
- Investigate retaliation complaints as a separate matter.
- Check on protection at 3 and 6 months.
- Stop and get help straight away if: a retaliation complaint has been made and no investigation has started within 10 working days.
1. Purpose
To set how speak-up reports are investigated and how the people who raise them are protected [EC].
2. Scope
| Applies to | All speak-up reports and all retaliation complaints |
| Locations | All services |
| When | From the day a report is received until protection is confirmed at 6 months |
| Does not apply to | Routine grievances (WRK-SOP-005) |
3. Definitions
| Term | Meaning |
|---|---|
| Retaliation | Any unfair treatment, such as dismissal, demotion, exclusion or a hostile change of duties, because a person raised a concern |
| Protection plan | A short written plan for how the reporter will be protected |
4. Background
Protection is what makes speak-up real. Without it, staff stay silent. A written protection plan is the test of whether protection is taken seriously.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Speak-up lead | Receives and logs reports, and writes the protection plan | Trained in confidentiality |
| Investigating officer | Investigates the concern and any retaliation | Independent of the issue |
| Chief executive | Acts on immediate danger and receives the outcome | Executive |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Speak-up report log | Confidential | Kept in a locked or access-controlled system |
7. Safety
- The reporter’s identity is protected. Share it only with those who need it, and only with the reporter’s agreement where possible.
8. Before you start
- Confirm the protection plan template is available to the speak-up lead.
9. Procedure
Step 1. Log and assess.
- Log the report on the speak-up log.
- Assess immediate risk to patients and to the reporter.
Key point: Immediate danger goes to the chief executive the same day.
Step 2. Write the protection plan.
- Agree with the reporter what protection they need.
- Record it on the plan, with a named contact.
Key point: Protection starts before the investigation ends.
Step 3. Investigate.
- Start the investigation within 10 working days.
- Keep the reporter informed at least every 4 weeks.
Key point: Regular contact is a protection.
Step 4. Check protection.
- Check at 3 and 6 months for any detriment.
- Record each check and any action taken.
Key point: Detriment after a report is treated as a new, serious matter.
10. Decision points
- If a retaliation complaint is upheld, the chief executive decides the remedy and any action against the person responsible.
11. Special situations
| Situation | Action |
|---|---|
| Reporter leaves the organisation | Protection checks continue for 6 months after leaving, where the reporter agrees. |
12. Escalation
- Any upheld retaliation, or any report that cannot be investigated, is reported to the board chair within 10 working days.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Protection plans in place for each reporter | 100% | Each report | Speak-up lead | Escalate to chief executive |
| Protection checks at 3 and 6 months | 100% | Quarterly | Speak-up lead | Escalate to chief executive |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Speak-up report log and protection plan | Confidential speak-up files | Employment plus 6 years |
15. Training
- Speak-up leads and investigating officers are trained in confidentiality, protection and fair investigation.
16. Related documents
| ID | Title | Use |
|---|---|---|
| WRK-POL-005 | Speak-up policy | Policy this procedure supports |
| WRK-SOP-005 | Staff grievance and investigation procedure | Separate route for routine issues |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
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)