The Care Act 2014 places statutory duties on local authorities and partner agencies, including care homes, to safeguard adults at risk. Robust documentation is essential for identifying patterns, supporting investigations, and demonstrating your commitment to protecting residents.
Types of Abuse to Document
Staff must recognise and document all forms of abuse. The Care Act identifies ten categories:
Physical abuse
Hitting, pushing, restraint, rough handling, medication misuse.
Emotional/psychological
Threats, humiliation, isolation, intimidation, verbal abuse.
Sexual abuse
Non-consensual sexual contact, inappropriate touching, exposure.
Neglect
Failure to provide care, nutrition, medication, or medical attention.
Financial abuse
Theft, fraud, coercion regarding money or possessions.
Discriminatory
Abuse based on race, gender, disability, sexuality, age.
Organisational
Poor practices, inadequate staffing, rigid routines, lack of choice.
Domestic abuse
Abuse by family member, partner, or someone in domestic setting.
Modern slavery
Human trafficking, forced labour, servitude.
Self-neglect
Failure to care for oneself, hoarding, refusing essential care.
Recognising and Recording Concerns
When any staff member identifies a potential safeguarding concern, they must document it immediately. Record:
What was observed or disclosed
Exact words used if a disclosure. Factual description of observations. No interpretation.
When it happened
Date, time, and duration if known. When was it discovered/disclosed.
Where it occurred
Specific location. Were others present? Environmental factors.
Who was involved
Alleged victim, alleged perpetrator, witnesses. Full names where known.
Immediate actions taken
How was safety ensured? Who was informed? Any first aid provided.
Physical evidence
Body maps if injuries. Photographs if appropriate. Preservation of evidence.
Recording Disclosures
When someone discloses abuse, listen without interrupting, don't ask leading questions, reassure them they did the right thing telling you, and explain you must pass the information on. Record their exact words in quotation marks immediately after.
The Safeguarding Referral Process
Document every step of the referral process:
Internal Reporting
- •Safeguarding lead notified
- •Date and time of notification
- •Initial discussion documented
- •Decision to refer or not (with reasons)
External Referral
- •Local authority safeguarding team contacted
- •Referral form submitted
- •Reference number obtained
- •Name of person referral made to
Police Involvement
- •When police were contacted
- •Crime reference number
- •Officer name and contact
- •Any immediate instructions given
Other Notifications
- •CQC notification (statutory)
- •Family notification (if appropriate)
- •Commissioner informed
- •Insurance company if needed
Investigation Documentation
If your home is asked to contribute to a Section 42 enquiry, or conducts an internal investigation, document:
- Terms of reference for the investigation
- Who is leading the investigation
- Witnesses interviewed and their statements
- Documents and records reviewed
- Timeline of events established
- Findings and conclusions
- Recommendations and action plan
Staff Involvement Records
When staff are involved in safeguarding matters (as alleged perpetrators or witnesses), document:
Allegations against staff
Suspension decision, LADO referral if children involved, HR involvement, investigation notes.
Staff as witnesses
Written statements requested, support offered, confidentiality reminded.
Disciplinary outcomes
Link to safeguarding case, DBS referral if dismissed/resigned, reference policy for future.
Training and support
Additional safeguarding training provided, supervision increased, wellbeing support offered.
Mental Capacity and Safeguarding
Safeguarding and mental capacity often intersect. Document:
- Capacity assessment for safeguarding decisions
- Resident's views and wishes (even if they lack capacity)
- Best interests decisions if lacking capacity
- Advocacy referral if no appropriate person
- Whether the resident consents to the referral (if they have capacity)
- Actions taken if capacity present but referral still made
Making Safeguarding Personal
Document the resident's desired outcomes from the safeguarding process. What do they want to happen? Revisit this throughout and record whether outcomes were achieved.
Body Maps and Injury Documentation
When documenting injuries that may relate to safeguarding:
- Use body maps to mark location of injuries
- Describe appearance: size, shape, colour, pattern, tenderness
- Photograph with consent (ruler for scale, good lighting)
- Record any explanation given for the injury
- Note if explanation is consistent with injury
- Document who was present during examination
- Date and sign all documentation
Patterns and Trends Analysis
Single incidents may not indicate abuse, but patterns might. Maintain:
- Incident logs that can be analysed for patterns
- Individual resident concern timelines
- Staff involvement tracking across incidents
- Location and time pattern analysis
- Regular safeguarding data review meetings
Safeguarding Governance
Document your safeguarding framework:
Safeguarding Policy
Comprehensive policy reviewed annually, covering all abuse types, reporting procedures, and staff responsibilities.
Named Safeguarding Lead
Designated person with documented role, responsibilities, and deputising arrangements.
Training Records
All staff trained at appropriate level. Safeguarding lead has advanced training.
Safeguarding Log
Central register of all safeguarding concerns, referrals, and outcomes.
Audit Programme
Regular audits of safeguarding practice, documentation quality, and policy compliance.
CQC Requirements
CQC inspectors specifically examine safeguarding. They check:
- Staff knowledge of safeguarding procedures
- Evidence concerns are identified and reported
- Timely referrals to local authority
- Appropriate CQC notifications submitted
- Learning from safeguarding incidents
- Multi-agency working relationships
- Resident involvement in safeguarding processes
Confidentiality and Information Sharing
Safeguarding information is highly sensitive. Document:
- Who has access to safeguarding records
- Information sharing decisions and rationale
- Consent obtained or lawful basis for sharing
- What was shared, with whom, and when
- Secure storage and retention of records
Record Retention
Safeguarding records should be retained for a minimum of 75 years from the date of birth of the individual, or 15 years from the last entry—whichever is longer. This enables future investigations if needed.
Learning from Safeguarding
After each safeguarding case, document lessons learned:
- What went well in the response
- What could have been done better
- System or process changes needed
- Training requirements identified
- Policy updates required
- How learning was shared with staff
Conclusion
Safeguarding documentation serves multiple purposes: it protects residents by ensuring concerns aren't overlooked, supports investigations with accurate evidence, demonstrates regulatory compliance, and enables learning from incidents.
The key principles are: record contemporaneously, stick to facts, use exact words for disclosures, document decisions and their rationale, and maintain confidentiality. When in doubt, always report and record—it's better to raise a concern that turns out to be unfounded than to miss signs of abuse.
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