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Policy · SAF-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: B1.14
At a glance
- Every adult who uses the facility is protected from abuse, neglect, exploitation and self-neglect.
- Any staff member who suspects abuse or neglect reports it the same day to the safeguarding lead.
- Every concern is recorded, referred to the right authority and followed up until an outcome is recorded.
- Adults who lack capacity are supported through the consent and best-interests process, and their views are sought.
- Stop and get help straight away if: a suspected abuse or neglect is not reported, or a concern has no referral or outcome recorded.
1. Purpose
To protect adults who use the facility from harm, and to set out what staff do when they suspect abuse or neglect (B1.14).
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 |
|---|---|
| Abuse | Any act or omission that harms an adult, including physical, sexual, emotional or financial abuse, neglect, exploitation, and discriminatory or institutional abuse. |
| Neglect | Failure to provide food, water, warmth, medicines, hygiene, supervision or care that the adult needs. |
| Self-neglect | An adult’s failure to care for their own health, safety or surroundings, where the risk is serious. |
| Capacity | An adult’s ability to understand, retain and weigh information to make a decision at the time it is needed. |
4. Background
To protect adults who use the facility from harm, and to set out what staff do when they suspect abuse or neglect (B1.14).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Safeguarding lead | Receives every concern, decides on referral, keeps the concern register, and reports to the clinical director | Clinical director |
| Any staff member | Reports a suspicion the same day, does not investigate alone, and records what they saw and heard | Safeguarding lead |
| Clinical director | Holds overall accountability and reviews the concern register each quarter | Governing body |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
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. Recognise.
- Note any sign of abuse or neglect: unexplained injury, distress, withdrawal, poor hygiene, unexplained money loss, or a change in behaviour.
- Record the facts as seen and heard, in the adult’s own words where possible. Do not ask leading questions.
Key point: Concern recognised and recorded.
Step 2. Report.
- Tell the safeguarding lead the same day. If the adult is at immediate risk, call emergency services first and then tell the lead.
- Do not tell the person suspected of the abuse.
Key point: Lead informed.
Step 3. Refer.
- The lead decides whether to refer to the statutory authority or the police, and records the reason and the time.
- Where the adult lacks capacity, follow the consent and best-interests process before referral where that is safe to do so.
Key point: Referral decided and recorded.
Step 4. Follow up.
- Record the outcome of every referral in the concern register.
- Check the adult’s safety and wellbeing after the referral, and review at the next team meeting.
Key point: Outcome recorded.
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 |
|---|---|---|---|---|
| Concerns reported the same day | 100% | Quarterly | Safeguarding lead | Retrain the team and review the route |
| Concerns with a recorded referral decision and outcome | 100% | Quarterly | Safeguarding lead | Escalate to the clinical director |
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
- All staff complete safeguarding training at induction and every year, with a recorded check of understanding.
- The safeguarding lead completes advanced training every two years.
16. Related documents
| ID | Title | Use |
|---|---|---|
| SAF-REG-001 | Adult safeguarding concern register (existing) | Register |
| PED-POL-002 | Child safeguarding (existing) | Policy |
| PSY-SOP-001 | Suicide risk screening and continuous observation (existing) | SOP |
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)