Standards › Standard 16 › Policies
Policy · PED-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 16.3
At a glance
- A named safeguarding lead for children is in place, and the name is posted in each area.
- All staff are trained to recognise and report abuse and neglect (WRK-REG-001).
- Every concern is written on PED-REG-001, reported to the lead and acted on the same day.
- A concern about a child is never held back because the signs are unclear.
- Stop and get help straight away if: a concern about a child is not reported or not acted on.
1. Purpose
To protect children from abuse and neglect by making sure concerns are recognised, reported and acted on (16.3).
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 can be harmed by the people who care for them, and the signs are often missed. A named lead, and staff who know how to recognise and report concern, are what protect them.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Safeguarding lead for children | Receives concerns, decides the action and keeps the register | Clinician or manager |
| All staff | Recognise, report and record any concern | All roles |
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. Name the lead.
- Name the safeguarding lead for children and post the name in each area.
Key point: Named and posted.
Step 2. Train staff.
- Train all staff to recognise and report abuse and neglect, and record it.
Key point: All trained.
Step 3. Report and act.
- Write each concern on PED-REG-001, report it to the lead and act the same day, referring to the statutory child protection service as national law requires.
Key point: Acted on the same day.
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 |
|---|---|---|---|---|
| Staff trained in child safeguarding | 100% | Quarterly | Safeguarding lead for children | Escalate to medical director |
| Concerns reported and acted on the same day | 100% | Each concern | Safeguarding lead for children | Escalate to medical 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
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| PED-REG-001 | Child safeguarding concern register | Register |
| WRK-REG-001 | Training matrix register (existing, reused) | Register |
| HOS-SOP-013 | Vulnerable patients and safeguarding (existing, reused) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Pocket book of hospital care for children (2013) and the UN Convention on the Rights of the Child (1989). |
| 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
Planned course: Child safeguarding in healthcare settings. New course planned.
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)