Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-013 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.16
At a glance
- Identify children, people with disability and patients who lack capacity at admission.
- Flag them on the record and in the care plan.
- Refer any concern to the named safeguarding lead the same day.
- Check the protections are in place at each review.
- Stop and get help straight away if: a child or adult at risk is admitted and no safeguarding check is recorded.
1. Purpose
To protect the patients most at risk of harm in hospital (S1.16).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Children, people with disability and patients who lack capacity can be harmed without anyone noticing. A named safeguarding lead and a flag in the care plan protect them.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Admitting nurse | Identifies and flags vulnerable patients | Trained |
| Safeguarding lead | Receives referrals; acts; keeps records | Named senior clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Vulnerability flag (HOS-FRM-010) | Current | On the admission record |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Identify.
- Ask the set questions at admission.
- Look for signs of abuse, neglect or lack of capacity.
Key point: Ask every patient.
Step 2. Flag and plan.
- Mark the flag on HOS-FRM-010.
- Write the protection in the care plan.
Key point: The flag must reach the care plan.
Step 3. Refer.
- Refer any concern to the safeguarding lead the same day.
Key point: Do not investigate alone.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Admissions with flag where it applies | At least 70% | Monthly | Safeguarding lead | Escalate to clinical director |
| Concerns referred the same day | 100% | Monthly | Safeguarding lead | Escalate to chief executive |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HOS-FRM-010 | Vulnerability flag record | Record |
| CON-SOP-001 | Informed consent before significant care | Consent for those who lack capacity |
17. Evidence
| Reference | Note |
|---|---|
| E-004 | ASF Expert Committee consensus on safeguarding. |
| 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 |
E-learning for this document
No e-learning course is linked to this document yet.
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)
- ASF Expert Committee (2026). Expert consensus. No external reference identified. (E-004)