1. Scope

1.1 Purpose

This policy sets out how provides care and support safely to every person who uses our supported living service. It meets Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It also supports the wider fundamental standards and the CQC key question: Is the service safe?

The policy aims to:

• prevent avoidable harm and the risk of harm
• make sure risks are assessed, recorded, reviewed and reduced as far as is reasonably practicable
• protect each person’s right to choice, independence and positive risk taking
• give staff clear steps to follow and show how we evidence safe practice

1.2 Application

This policy applies to all employed staff, bank and agency workers, students, volunteers and contractors working for . It applies in every setting where we deliver support. This includes people’s own homes, shared houses, flats, and community settings such as shops, transport and activities.

1.3 Service context

Under the Bundle Package, provides personal care and support that is separate from the person’s housing. The person holds a tenancy or licence. Tenancy rights, landlord duties and our care duties must be kept distinct. We must not make a person’s tenancy depend on accepting our care.

1.4 What safe care and treatment covers

• Risk assessment and risk management
• Staff competence, skills and supervision
• Safe premises, equipment and the home environment
• Medicines support
• Infection prevention and control
• Recognising and responding to health deterioration and emergencies
• Consent, capacity and least restrictive practice
• Safe sharing of care across services, including hospital transfers

1.5 Who we support

We support adults, which may include people with learning disabilities, autism, mental health needs, physical disabilities, sensory impairment or long term conditions. Some people may have complex health needs or behaviours that challenge. The policy applies equally to all of them.

1.6 Limits of responsibility

Where a landlord or housing provider is responsible for the structure, gas, electrical and fire safety of a building, we must still check that those duties are met. We must escalate any shortfall we see. We must not assume that someone else has acted.

2. Legal and Regulatory Framework

Legislation/Regulation	Requirements
Health and Social Care Act 2008	Sets up CQC and requires registration for regulated activities. It also provides the statutory Code of Practice on the prevention and control of infections, which providers must have regard to.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014	Regulation 12 requires safe care and treatment, including risk assessment, competent staff, safe premises and equipment, safe medicines management and infection control. Regulation 9 (person-centred care), 11 (consent), 13 (safeguarding), 17 (good governance), 18 (staffing), 19 (fit and proper persons) and 20 (duty of candour) also apply.
Care Act 2014	Requires wellbeing, prevention of harm and person-centred assessment. Sets out statutory adult safeguarding duties and the roles of the local authority and Safeguarding Adults Board.
Mental Capacity Act 2005 and Code of Practice	Requires capacity to be presumed, decisions to be made in a person’s best interests where capacity is lacking, and the least restrictive option to be used. In supported living, any deprivation of liberty must be authorised by the Court of Protection. Staff must follow current government guidance on the Supreme Court judgment of June 2026 (AGNI) on deprivation of liberty.
Health and Safety at Work etc. Act 1974 and Management of Health and Safety at Work Regulations 1999	Require employers to protect the health and safety of employees and others affected by their work. They require suitable and sufficient risk assessments and arrangements for competent advice.
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)	Require reporting of specified work-related deaths, serious injuries, diseases and dangerous occurrences to the Health and Safety Executive.
Control of Substances Hazardous to Health Regulations 2002; Manual Handling Operations Regulations 1992; Provision and Use of Work Equipment Regulations 1998; Lifting Operations and Lifting Equipment Regulations 1998	Require hazardous substances, manual handling tasks, work equipment and lifting equipment to be assessed, controlled, maintained and, where required, thoroughly examined.
Regulatory Reform (Fire Safety) Order 2005	Requires a fire risk assessment, fire precautions, and emergency plans for premises. Personal emergency evacuation plans must reflect each person’s needs.
UK GDPR and Data Protection Act 2018	Govern lawful, fair and secure processing of personal and health data. They require records to be accurate, kept secure, shared only where lawful, and breaches to be managed.
Human Medicines Regulations 2012 and NICE guideline NG67 (Managing medicines for adults receiving social care in the community)	Control the supply, administration and storage of prescription-only medicines. NG67 sets best practice for medicines support, recording, errors and covert or time-critical medicines.
Equality Act 2010 and Human Rights Act 1998	Require freedom from discrimination, reasonable adjustments, and respect for rights such as life, freedom from degrading treatment, liberty and private life.
Health and Care Act 2022, section 181	Requires registered providers to ensure staff receive learning disability and autism training appropriate to their role. This is delivered through the Oliver McGowan Mandatory Training.

CQC currently assesses services against the five key questions using its assessment framework and quality statements. CQC is moving to sector-specific frameworks. The fundamental standards and legal duties above are not changing. This policy will be reviewed when CQC confirms the new framework.

3. Definitions of Key Terms

Term	Definition
Safe care and treatment	Care that is planned and delivered to prevent avoidable harm, with risks assessed and reduced as far as is reasonably practicable.
Reasonably practicable	The standard of weighing the size of a risk against the time, cost and effort needed to reduce it. It does not require a risk free service.
Risk assessment	A recorded process of identifying hazards, deciding who may be harmed, evaluating the level of risk and setting controls.
Positive risk taking	Supporting a person to take informed risks that help them achieve their goals and independence, with sensible controls in place.
Supported living	A model where a person lives in their own home under a tenancy or licence and receives personal care and support from a separate provider.
Bundle Package	The way arranges a package of support hours and related services to meet a person’s agreed outcomes.
Care and support plan	The person-centred record of a person’s needs, preferences, goals and the agreed way staff will support them.
Mental capacity	The ability to make a specific decision at a specific time, as defined by the Mental Capacity Act 2005.
Best interests decision	A decision made for a person who lacks capacity for that decision, following the Mental Capacity Act 2005 checklist.
Restrictive practice	Any intervention that limits a person’s movement, liberty or freedom to act independently, including physical, mechanical, chemical and environmental restrictions.
Medicines error	Any unintended event in the prescribing, supply, support or recording of medicines that leads, or could lead, to harm.
Infection prevention and control (IPC)	Practices that stop the spread of infection, including hand hygiene, personal protective equipment and safe cleaning.
Deterioration	A noticeable decline in a person’s physical or mental health that may need prompt escalation or emergency treatment.
Duty of candour	The legal duty under Regulation 20 to be open and honest with people, and to apologise, when a notifiable safety incident occurs.
Delegated healthcare task	A clinical task, such as insulin administration or gastrostomy feeding, taught to a support worker by a registered health professional for a named person.

4. Policy Statement

4.1 Commitment

is committed to providing care and support that is safe, lawful and respectful. We will assess risks to each person’s health and safety. We will do all that is reasonably practicable to reduce them. We will not remove choice or independence simply to remove risk.

4.2 Core Principles

• Person-centred: each person is involved in assessing and managing risks that affect them.
• Proportionate: controls match the level of risk and the person’s wishes.
• Least restrictive: we choose the option that limits rights and freedoms the least.
• Competent: only trained and assessed staff carry out care tasks.
• Open and learning: we report incidents, share learning and are honest when things go wrong.
• Collaborative: we work with families, advocates, health services, commissioners and landlords.

4.3 Safe staffing

We will maintain enough suitably skilled staff on every shift to meet the assessed needs of the people we support. Rotas will be planned to match support hours, competence and any one-to-one or two-to-one needs. Agency use will be minimised, and agency staff must be inducted before lone working.

4.4 Equality and rights

We will make reasonable adjustments, communicate in each person’s preferred way and apply this policy without discrimination. Decisions will respect the Human Rights Act 1998.

4.5 Accountability

Every member of staff is accountable for safe practice. Managers are accountable for the systems that make safe practice possible. Failure to follow this policy may lead to disciplinary action.

5. Roles and Responsibilities

Role	Responsibilities
All Staff	Follow care plans, risk assessments and this policy at all times. Work only within their training and competence. Record care accurately and at the time it is given. Report incidents, near misses, hazards and concerns immediately. Challenge unsafe practice and use the whistleblowing route if needed.
Registered Manager ()	Hold overall accountability for compliance with Regulation 12 and strategic oversight of safety. Ensure safe staffing, supervision, training and governance systems. Review incident trends, audit results and action plans. Make statutory notifications to CQC and meet the duty of candour. Report safety risks to the provider’s leadership.
Duty Manager	Provide day to day operational leadership and make frontline decisions during their shift. Coordinate the response to incidents, medical emergencies and unexpected absences. Supervise staff on shift, check that care is given as planned and deploy staff safely. Check that medicines, records and handovers are completed. Escalate serious incidents to the Registered Manager without delay.
Safeguarding Lead ()	Advise staff on safeguarding concerns and decide on referrals. Make referrals to the local authority and liaise with police and CQC. Check that safeguarding actions are linked to updated risk assessments.
Health and Safety Officer ()	Oversee workplace and home environment risk assessments, equipment checks and fire safety arrangements. Maintain accident records and report under RIDDOR where required. Check that landlords meet their duties and escalate shortfalls.
Data Protection Officer ()	Advise on UK GDPR compliance for care records, risk information and information sharing. Manage data breaches and decide on reporting to the Information Commissioner’s Office. Oversee subject access requests.
Medicines Lead	Maintain medicines procedures, audits and competency assessments. Review all medicines errors and check that learning is shared. Liaise with GPs and pharmacists on medicines reviews.
Infection Prevention and Control Lead	Maintain IPC procedures, audits and outbreak plans. Check supplies of personal protective equipment and cleaning materials. Advise staff on infection risk for each person.

6. Procedures

6.1 Assessment and risk identification

1. Complete a full needs and risk assessment before support starts, using information from the commissioner, the person, family and health professionals.
2. Identify risks to the person and to staff. Consider health conditions, mobility, nutrition, choking, epilepsy, mental health, behaviour, medicines, finances, exploitation, fire and the home environment.
3. Record each risk, who may be harmed, the level of risk and the controls agreed.
4. Agree the assessment with the person. Use accessible formats and an advocate if the person needs one.
5. Review risk assessments at least every six months, and sooner after any incident, hospital stay or change in need.

6.2 Care planning and positive risk taking

1. Write a care and support plan that turns each risk assessment into clear, practical instructions.
2. Record the person’s goals and the benefits of any risk they choose to take.
3. Where a person chooses a risk, record the discussion, their capacity for that decision and the support agreed.
4. Make plans available to all staff in the home before they provide care.
5. Record any change in the daily notes and update the plan within 24 hours.

6.3 Medicines support

1. Record whether the person manages their own medicines, needs prompting or needs staff to administer them.
2. Only staff who have completed training and have been observed as competent may support medicines.
3. Check the medicine, person, dose, time and route against the medicines administration record (MAR) or approved record every time.
4. Sign the MAR immediately after support is given. Never sign in advance.
5. Store medicines securely. Record temperatures for items needing refrigeration. Manage controlled drugs in line with legal requirements.
6. For PRN (as required) medicines, follow a written protocol that states when and why to offer them.
7. Do not give covert medicines unless a best interests decision, pharmacist advice and prescriber agreement are recorded.
8. Report any error to the Duty Manager at once, seek medical advice, and record it as an incident.
9. Carry out a medicines audit at least monthly.

6.4 Infection prevention and control

1. Wash hands before and after care, using the correct technique.
2. Wear gloves and aprons for personal care and when handling bodily fluids, then dispose of them safely.
3. Use colour-coded cleaning equipment and clean frequently touched surfaces daily.
4. Handle laundry safely and wash soiled items at the correct temperature.
5. Staff with diarrhoea, vomiting or other infectious symptoms must not work until the exclusion period set out in guidance has passed.
6. If two or more people have similar symptoms, inform the Duty Manager, isolate where practicable and contact the UKHSA health protection team and the person’s GP.
7. Make sure people are offered vaccinations, such as flu and COVID-19, as recommended.

6.5 Premises, equipment and environment

1. Check each home for hazards at induction and during monthly visits. Include fire, electrical, gas, water temperature, trip hazards and security.
2. Report defects to the landlord in writing and record the response. Escalate to the commissioning team if serious risks remain unresolved.
3. Test fire alarms weekly where fitted. Record fire drills and keep personal emergency evacuation plans up to date.
4. Keep a register of all equipment we supply or use, such as hoists, bath aids and monitors. Record service and examination dates.
5. Remove faulty equipment from use at once, label it and report it.
6. Check water safety, including legionella controls, in line with the landlord’s risk assessment.

6.6 Recognising and responding to deterioration

1. Learn each person’s usual baseline, such as eating, mood, mobility, skin and breathing.
2. Look for warning signs such as confusion, fever, breathlessness, pain, falls, pressure damage or reduced intake.
3. Use a recognised structured tool, such as RESTORE2 where used locally, to record observations and decide on action.
4. Call 999 straight away for life-threatening emergencies. Stay with the person and give first aid within your training.
5. For urgent but non-life-threatening needs, call the GP or NHS 111 and record advice received.
6. Tell the Duty Manager, the family where agreed, and update the care plan.

6.7 Consent, capacity and restrictive practice

1. Always seek the person’s consent before care. Assume capacity unless there is evidence otherwise.
2. If capacity is in doubt, assess it for the specific decision. Record the assessment and the support given to help the person decide.
3. Where a person lacks capacity, hold a best interests decision involving the person, family, advocate and professionals.
4. Use restrictive practice only as a last resort, for the shortest time, and only where legally justified. Record every use and review it.
5. Where arrangements may amount to a deprivation of liberty, tell the Registered Manager. They will contact the commissioner and local authority team so that Court of Protection authorisation can be considered under current guidance.
6. Offer independent advocacy where a person has no suitable representative.

6.8 Transitions and shared care

1. Prepare a hospital passport for each person. Include communication needs, medicines, health conditions and risks.
2. When a person goes to hospital, send the passport, current medicines list and a staff contact number.
3. Share relevant risk information with GPs, community nurses, day services and families, in line with UK GDPR.
4. On return from hospital, obtain discharge information, update the care plan, check medicines changes and reassess risks.
5. Use structured handovers at every shift change. Record key events and outstanding actions.

6.9 Incident response and duty of candour

1. Make the person safe and get medical help if needed.
2. Tell the Duty Manager immediately.
3. Complete an incident form before the end of the shift.
4. The Registered Manager decides whether the incident is a notifiable safety incident. If so, they will inform the person or their representative, apologise, explain what happened and confirm in writing.
5. If a safeguarding concern arises, inform the Safeguarding Lead, who will consider a referral to the adult safeguarding team.
6. Review the incident for causes, update the risk assessment and share lessons at team meetings.

6.10 Medicines support: self-administration, reconciliation, reviews and psychotropic stewardship

This subsection adds detail to section 6.3 and follows NICE guideline NG67. The Medicines Lead keeps the supporting forms and templates.

Self-administration

1. Before a person manages any of their own medicines, the Duty Manager or Medicines Lead completes a self-administration risk assessment with the person.
2. The assessment covers the person’s understanding of each medicine, ability to read labels and open packaging, memory, safe storage, risk to others in the home, and any risk of overdose or self-harm.
3. Agree and record the level of support: independent, prompting, partial help or full administration.
4. Review the assessment after any change in health, medicines or home circumstances, after an incident and at each medication review.

Medicines reconciliation on transfer

• When a person returns from hospital or another service, compare the discharge list with the MAR, the GP record and the pharmacy supply on the same day.
• Do not give a changed or new medicine until the difference is clarified with the prescriber or pharmacist.
• Where a MAR entry is handwritten, a second trained member of staff checks and signs it.

Ordering, receipt and disposal

• Order from the current repeat list, checked against the MAR. Check each delivery against the order and record quantities received and carried forward.
• Return unwanted, expired or discontinued medicines to the pharmacy and record the return. Do not put them in household waste or down the drain.

Topical medicines, homely remedies and time-critical medicines

• Use a topical MAR and a body map for creams, patches and ointments. Show where, how much and how often to apply, and record the date opened. Warn staff about the fire risk of paraffin-based emollients on clothing and bedding.
• Give homely remedies only under a written protocol agreed with the GP or pharmacist for that person, for a limited period, and record every dose.
• Mark time-critical medicines on the MAR, for example Parkinson’s medicines, insulin and anti-seizure medicines. If a dose cannot be given in the agreed window, seek clinical advice at once.

Structured medication reviews

Request a structured review from the GP or pharmacist at least once a year, and after any hospital stay or significant change. Staff prepare observations, side effects and PRN use beforehand. Record the outcome and update the MAR and care plan.

Psychotropic stewardship (STOMP and STAMP)

• For anyone with a learning disability or who is autistic, record why each psychotropic medicine was prescribed and when it is next due for review.
• Raise with the prescriber whether the medicine is still needed and whether non-drug support would work better.
• Never stop or reduce a psychotropic medicine without prescriber advice.
• Record every PRN psychotropic dose with the reason and the effect. Never use medicines to control behaviour for staff convenience.

6.11 Duty of candour: notifiable safety incidents and process

This subsection expands section 6.9 and applies Regulation 20. The Registered Manager () is accountable for compliance. The Duty Manager must raise any possible notifiable incident without delay.

What is a notifiable safety incident

It is an unintended or unexpected incident in the provision of care that, in the reasonable opinion of a registered health professional or the Registered Manager, has resulted in, or could result in, one of the following:

• death of the person, where the death relates directly to the incident and not to the person’s underlying condition
• severe harm, meaning a permanent lessening of bodily, sensory, motor, physiological or intellectual function
• moderate harm, meaning significant but not permanent harm, or a moderate increase in treatment such as unplanned hospital care, extra time in hospital or a further procedure
• prolonged psychological harm, meaning psychological harm that has lasted, or is likely to last, at least 28 continuous days

If there is doubt, treat the incident as notifiable until the Registered Manager decides otherwise. Record the decision and the reasons.

Process

1. Make the person safe, get medical help and report the incident to the Duty Manager at once.
2. The Registered Manager decides whether the harm threshold is met as soon as the facts are known. Do not wait for the full investigation.
3. Tell the person, or their representative if the person lacks capacity or has asked for this, as soon as reasonably practicable. Do this in person where possible, in an accessible format and with an advocate if wanted.
4. Give a truthful account of what is known, say what is not yet known and apologise. An apology is not an admission of legal liability.
5. Offer reasonable support, such as a named contact, emotional support, help to attend meetings and information on how to complain.
6. Investigate, then give the person the findings and the actions taken.
7. Confirm the notification in writing, including the account, the apology, the enquiries to follow and the support offered. Keep a copy.

Records

Keep a record of the decision, the date and method of each conversation, who was present, the written notice and any reply. If the person cannot be contacted or declines to engage, record each attempt. Check duty of candour compliance in the monthly audit and in the quality indicators in section 8.2. Where the incident also meets a CQC notification test, follow section 11.

6.12 Deprivation of liberty after the AGNI judgment

This subsection adds practical steps to sections 6.7 and 14.4. On 2 June 2026 the Supreme Court in AGNI replaced the Cheshire West acid test with a multifactorial assessment. Continuous supervision and control, and not being free to leave, no longer decide the question alone. A person may give valid consent to their arrangements through their expressed wishes and feelings, if they understand enough to know whether they are happy or unhappy with them. Staff must follow the current DHSC and CQC guidance, which may change. Staff do not decide whether a deprivation of liberty exists. Their task is to gather and record accurate evidence and escalate.

Step by step

1. For each person, list every arrangement that limits their freedom. Examples are locked doors, constant supervision, escorting outside, restricted contact, restricted access to money, belongings or the kitchen, and technology such as door sensors.
2. Record for each arrangement why it is used, who agreed it, how long it applies and what less restrictive options were tried.
3. Record the person’s wishes and feelings about where they live and how they are supported. Use their communication methods and note both verbal and non-verbal signs.
4. Record any sign of objection, such as attempts to leave, distress, refusal or repeated requests. Do not assume that a lack of objection means consent.
5. Record what the person understands about their arrangements and whether they appear to accept them. Do not treat this as the same as a capacity assessment under the Mental Capacity Act 2005.
6. Tell the Registered Manager the same day when you see objection, new restrictions or changes in the person’s understanding.

Review and escalation

• The Registered Manager reviews all recorded restrictions at least every six months, and sooner after any change, incident or objection.
• Where the evidence suggests the person may be deprived of their liberty, the Registered Manager refers to the local authority team and informs the commissioning team. In supported living, authorisation is sought from the Court of Protection.
• Keep arrangements as least restrictive as possible while a decision is awaited. Record that the referral was made and the response.
• Offer an independent advocate to the person, and consult family and other people who know them well.
• Notify the CQC of the outcome of any Court of Protection application, as set out in section 11.

6.13 Restrictive practice, restraint and positive behaviour support

This subsection builds on section 6.7 and Regulation 13(4) and (5). Control or restraint may be used only where it is necessary to prevent harm and is a proportionate response to the likelihood and seriousness of that harm. follows CQC’s Right support, right care, right culture and aims to reduce restrictive practice.

Types of restriction

Type	Examples
Physical	Holds, guiding or blocking a person’s movement against their wishes
Mechanical	Belts, straps or equipment that limit movement
Chemical	Medicines given mainly to control behaviour rather than treat a condition
Environmental	Locked doors, restricted access to rooms, food, money or belongings

Seclusion and prone restraint are not part of any plan in this service. Environmental and chemical restrictions must be recorded and reviewed in the same way as physical ones.

Behaviour support plans

• Each person with behaviours that challenge has an individual positive behaviour support plan, written with them, their family and specialists.
• The plan states known triggers, early warning signs, proactive strategies, de-escalation steps and any agreed physical intervention, with the reasons it is needed.
• Staff must read the plan before supporting the person. Review it after every use of restraint and at least every six months.

Competence standards

Staff may use physical intervention only if they have completed training that meets the Restraint Reduction Network Training Standards, and only the techniques taught for that person. Competence is assessed and refreshed in line with section 7.2.

After an incident

1. Check the person for injury and get medical help if needed.
2. Record what happened, the trigger, what was tried first, the technique used, its duration and who was present.
3. Hold a debrief with the person, using their communication method, and a separate debrief with staff within 24 hours.
4. The Registered Manager reviews the record, considers a safeguarding referral if the use was not justified, and updates the plan.

Monitoring and reduction

The Registered Manager analyses all restrictive practice monthly by person, time, staff and trigger. Findings go to the governance meeting with a reduction plan. Any restriction used regularly must be considered for a deprivation of liberty referral under section 6.7.

6.14 Infection prevention and control: outbreaks, sharps, waste and audit

This subsection adds to section 6.4 and applies the Health and Social Care Act 2008 Code of Practice on infection prevention and control and the national infection prevention and control manual for England. The Infection Prevention and Control Lead keeps the outbreak plan up to date.

Outbreak plan

1. The Duty Manager records affected people and staff, symptoms and start dates, and tells the Registered Manager.
2. Contact the UKHSA health protection team and the GP for advice on testing, isolation and exclusion. Follow their written advice.
3. Inform the commissioning team and the CQC where the outbreak affects safe running of the service.
4. Dedicate equipment and, where practicable, staff to affected people. Increase cleaning of touched surfaces and bathrooms.
5. Arrange testing only as advised by health professionals. Do not use blanket visitor bans. Agree safe visiting with each person, ask visitors to follow IPC advice and record decisions.
6. Declare the outbreak over only when advised. Review lessons learned.

Sharps and needlestick injuries

• Use a sharps bin that meets standards. Never re-sheath, bend or break needles. Do not overfill bins.
• After a sharps injury, encourage bleeding, wash with soap and running water, and cover. Do not scrub or suck the wound.
• Get urgent advice from occupational health, NHS 111 or an emergency department. Report to the Duty Manager and complete an incident form. The Health and Safety Officer considers RIDDOR.

Waste

• Separate household, offensive and infectious clinical waste, using the correct colour-coded bags or containers.
• Store waste securely away from people’s food areas until collection by a licensed carrier. Keep consignment records.

PPE selection

Apply standard precautions to everyone. Choose gloves, aprons, masks and eye protection by assessing the task, the risk of contact with body fluids and any transmission-based precautions advised. Put on and remove PPE in the right order, and dispose of it after each task.

Cleaning and water hygiene

• Keep a cleaning schedule for each home, with tasks, frequency and sign-off.
• Flush little-used taps and showers, check hot and cold water temperatures and descale showerheads as set out in the legionella risk assessment. Report concerns to the landlord in writing.

Audit cycle

The IPC Lead audits each home quarterly using a standard tool. Findings go into an action plan with owners and dates, and results are reported to the Registered Manager and the governance meeting.

6.15 Emergency, contingency and business continuity planning

Regulation 12 requires safe care to continue in foreseeable emergencies. Regulation 17 requires risks to be managed through governance. This subsection sets out how prepares for and responds to disruption. It links to the Business Continuity and Emergency Planning Policy and the service risk register.

Preparation

• The Registered Manager keeps a continuity plan listing the critical activities: medicines, personal care, nutrition, safe moving, communication and access to health care.
• Rate each person’s dependency, for example on oxygen, powered equipment, time-critical medicines or one-to-one support. Higher dependency people are protected first.
• Keep an emergency contact list, a list of alternative staff and keyholders, and a grab sheet with the key details of each person.
• Test the plan through a scenario exercise at least once a year and record the learning.

Response by scenario

Event	Immediate actions
Staff shortage	Duty Manager reviews risk and prioritises critical tasks. Use the on-call manager, bank staff and other homes. Escalate to the commissioning team if safe care cannot be assured.
Loss of power or heating	Check powered equipment and medicines needing refrigeration. Use backup power and torches. Contact the supplier and ask whether the person is on the priority services register.
Flood or fire damage	Make the home safe. Move people and records to safe areas. Inform the landlord and the commissioner.
Severe weather	Plan staff travel ahead. Prioritise critical visits. Keep stocks of food, medicines and warm clothing.
IT or system failure	Switch to paper care plans, MARs and grab sheets. Enter records later and report any data risk to the Data Protection Officer.
Evacuation	Call 999 for fire. Follow personal emergency evacuation plans. Account for everyone, take medicines and grab sheets if safe, and move to the agreed place.

Working with partners

For wide-area emergencies, contact the emergency planning team and the commissioning team for support and information. Notify the CQC of events that stop or may stop the service running safely, as set out in section 11.

Recovery and review

After any event, the Registered Manager holds a debrief, updates the plan and risk register and records the lessons in the action plan.

6.16 Condition-specific risk protocols and structured health monitoring

Regulation 12(2)(a) and (b) require risks to be assessed and mitigated for each person. Where a person has any of the conditions below, a written protocol is part of their care plan. A relevant health professional, such as the GP, epilepsy nurse, speech and language therapist or diabetes nurse, must agree it. Staff follow the person’s own protocol and complete the training in section 7.2 first.

Condition	Minimum content of the protocol
Epilepsy	Seizure types, triggers, what to do, when rescue medication is given, when to call 999, recovery care, and a seizure record.
Choking and dysphagia	Texture and fluid levels set by the speech and language therapist, positioning, supervision at meals and the emergency response.
Diabetes	Monitoring routine, signs and treatment of low and high blood glucose, medicines and food, and when to seek urgent help.
Pressure ulcers	Skin checks, repositioning, pressure-relieving equipment, nutrition and referral to the community nurse at first sign of damage.
Falls	Contributing factors, footwear, aids, medicines review, post-fall checks and when to call for help.
Constipation	Bowel chart, stool type recording, fluids, diet, laxative guidance and escalation if bowels are not open as agreed.
Sepsis	Signs to look for, such as fever or low temperature, fast breathing, confusion or mottled skin. Call 999 or NHS 111 and say you are worried about sepsis.

Structured monitoring and escalation

• Where staff are trained and the person’s health team agrees, record observations on a structured tool such as NEWS2 and act on the score.
• For people who cannot say they feel unwell, record their usual baseline and watch for soft signs. These include changes in eating, sleep, mood, behaviour, continence, skin colour and mobility.
• A change in behaviour may signal pain or illness. Check for a physical cause before assuming a behavioural one.
• Escalate in line with section 13.3. State clearly what is different from the person’s normal.

Annual health checks

Make sure each eligible person with a learning disability is offered an annual health check with their GP and has a health action plan. Prepare for the check with the person, share the plan and record the outcome and agreed actions. Use the results to update risk assessments.

6.17 Advance care planning, DNACPR and end of life care

Staff must know before an emergency what a person has decided or what has been decided lawfully for them. Regulation 11 and the Mental Capacity Act 2005 require valid consent or a best interests decision. Support staff never make, change or cancel a DNACPR or treatment escalation decision.

Documents staff may meet

• ReSPECT form or DNACPR form: a recommendation made by a clinician, with the person or, where they lack capacity, after a best interests process. Check it names the right person and is signed and in date where it states a review date.
• Advance decision to refuse treatment: must be written, signed and witnessed to refuse life-sustaining treatment, and must state that it applies even if life is at risk. If valid and applicable, it is binding.
• Lasting Power of Attorney for health and welfare: check it has been registered with the Office of the Public Guardian. The attorney may decide only if the person lacks capacity and only within the terms of the document.
• Advance statement of wishes: not binding, but must be considered in any best interests decision.

Making them available

1. Keep the original, or a copy that is legally acceptable, in one agreed place that all staff know, such as the front of the care file.
2. Record on the grab sheet that a form exists and where it is kept.
3. Send a copy with the person to hospital or with ambulance crews and record that this was done.
4. Check the documents at each care plan review and after hospital stays.

In a cardiac arrest

• Call 999 straight away and tell the call handler about any form.
• If there is a valid DNACPR form, do not start CPR. Provide comfort and dignity and follow the call handler’s instructions.
• If there is no valid form, or you are unsure, start CPR within your training until the ambulance crew takes over.
• Never withhold CPR because of a person’s age, disability or learning disability alone.

End of life care

Record the person’s preferences for place of care, people they want present, spiritual and cultural needs, and comfort measures. Work with the GP, community nurses and palliative care team. Make sure anticipatory medicines are available and staff are trained to support them. Support family and other residents. After a death, follow section 11 and the duty of candour.

6.18 Missing person and mental health crisis response

The Duty Manager leads the response to an unexpected absence or a mental health crisis, with advice from the on-call manager. Each person’s care plan sets out their individual risk rating and their usual patterns. Staff must not wait to be certain that a person is missing before acting if there is concern for their safety.

Missing person procedure

1. Rate the risk using the person’s plan. High risk includes risk to life, such as suicidal thoughts, vulnerability, a medical emergency, medicines needed urgently, or danger to others. Medium risk means a likelihood of harm but not immediate danger. Low risk means no significant risk is expected and the absence is out of character.
2. Search the home and immediate area, then known places. Phone the person and contacts they may have gone to.
3. Call 999 at once for high risk. For medium risk, call the police without delay, using the non-emergency number. For low risk, tell the Duty Manager and set a review time in line with the plan.
4. Give police a description, a recent photograph if consent or best interests allow, clothing, medicines, risks and places of significance.
5. Inform the Registered Manager, family or representative where agreed, and the commissioner and social worker.
6. Record times and actions. Review the risk rating after each hour of absence or when new information arrives.

When the person returns, check their health and welfare, offer a conversation about what happened and why, and tell the police. Update the risk assessment and consider a safeguarding concern. Notify the CQC if police are involved, as set out in section 11.

Self-harm, suicide risk and mental health crisis

• Stay with the person, stay calm and listen without judgement. Ask directly about thoughts of suicide or self-harm.
• Remove or reduce access to means where this can be done safely, including medicines and sharp items.
• Call 999 if there is immediate danger or serious injury. Give first aid within your training.
• If there is no immediate danger, call NHS 111 and choose the mental health option, or contact the person’s crisis plan contacts or care coordinator. Samaritans on 116 123 is available for the person or staff.
• Keep close observation until a clinician has assessed the person. Record the level of observation.
• Tell the Duty Manager, who informs the Registered Manager. Notify the commissioner and CQC if required.
• Update the risk assessment and crisis plan after the event. Offer debrief and support to the person and staff.

7. Training and Development

7.1 Induction and mandatory training

All new staff must complete induction before working unsupervised. This includes the Care Certificate where staff are new to care. Staff must complete the following, refreshed at the intervals set by :

• Risk assessment and positive risk taking
• Health and safety, fire safety and first aid
• Moving and handling
• Infection prevention and control
• Medicines support
• Safeguarding adults and the Mental Capacity Act
• Basic life support and emergency response
• Information governance and record keeping
• Food hygiene, nutrition and hydration, including choking awareness
• Oliver McGowan Mandatory Training on learning disability and autism, at the tier suited to the role

7.2 Specialist training

Staff supporting people with specific needs must complete specialist training before supporting them. Examples include epilepsy and rescue medication, diabetes, dysphagia, PEG feeding, positive behaviour support and de-escalation. Delegated healthcare tasks must be taught by a registered health professional. Competence is signed off for each named person, and repeated at least annually.

7.3 Competency assessment

1. A trained assessor directly observes practice in the person’s home.
2. Competence is recorded against clear criteria.
3. For medicines, staff are observed at induction and at least annually, and after any error.
4. Staff who are not yet competent must be supervised and receive further training. They must not carry out the task alone.
5. Records of training, observations and sign-off are held in staff files.

7.4 Supervision and appraisal

Staff receive regular supervision, at least every two months, with an annual appraisal. Supervision covers safe practice, incidents, wellbeing, learning needs and any concerns. The Duty Manager provides on-shift supervision and spot checks.

7.5 Continuous learning

• Share learning from incidents, audits, complaints and national reports at team meetings.
• Use reflective practice after significant events.
• Support staff to gain qualifications and to keep a record of their development.
• Update training when law, guidance or people’s needs change.

8. Monitoring and Review

8.1 Monitoring framework

The Registered Manager oversees a programme of checks to confirm that this policy works in practice. The programme includes:

• Monthly audits of care plans, risk assessments, daily records and MAR charts
• Monthly medicines audits and stock checks
• Quarterly IPC, health and safety and environment audits
• Spot checks, including out of hours and night visits
• Review of incidents, near misses, falls and safeguarding concerns for trends
• Feedback from people, families, staff, professionals and commissioners

8.2 Quality indicators

• Percentage of risk assessments reviewed within the agreed timescale
• Number and type of medicines errors, and the percentage reviewed within seven days
• Number of falls, pressure ulcers, hospital admissions and emergency calls
• Percentage of staff with up to date mandatory training and competency sign-off
• Supervision and appraisal completion rates
• Percentage of audit actions completed on time
• Number of restrictive practices used and reviewed
• Equipment and fire safety checks completed on time
• Incidents reported within the required time, and duty of candour completed

8.3 Policy review

This policy is reviewed at least annually by the Registered Manager. It is also reviewed after a serious incident, a CQC or commissioner finding, or a change in law or guidance. Reviews will check the policy against the five CQC key questions and the current assessment framework. Staff and people who use the service are invited to comment.

8.4 Continuous improvement

1. Record every audit finding in an action plan with an owner and a deadline.
2. Report progress to the Registered Manager each month.
3. Check that completed actions have made a difference.
4. Share outcomes with staff and people using the service.
5. Keep evidence of improvement ready for CQC and commissioners.

9. Reporting Concerns

9.1 Duty to report

Every member of staff at has a duty to report any concern about the safety of care, treatment or support. This duty applies whether the concern is minor or serious. It applies to concerns about people we support, colleagues, managers, visitors, other professionals and the environment.

Staff must report:

• any incident, near miss or unsafe practice linked to safe care and treatment
• medicines errors, missed doses and gaps in stock or records
• signs of abuse, neglect, self-neglect, exploitation or discrimination
• unsafe staffing levels, missed visits or unsafe lone working
• faulty equipment, hazards in a person’s home or breaches of infection prevention and control
• poor practice, bullying, or behaviour that falls below the fundamental standards
• any breach, or suspected breach, of confidentiality

Failing to report a concern is a conduct matter. Staff who act in good faith will be supported.

9.2 Reporting channels

Staff can choose the route that feels safest for them. They do not need to ask permission to raise a concern.

1. Tell the Duty Manager on shift straight away if there is risk to a person’s safety.
2. If the concern involves the Duty Manager, speak to the Registered Manager ().
3. For safeguarding concerns, speak to the Safeguarding Lead () or the Registered Manager.
4. For health and safety hazards, speak to the Health and Safety Officer ().
5. For data breaches, speak to the Data Protection Officer ().
6. If the concern involves senior leaders, or staff do not feel it has been addressed, escalate to the nominated individual or the directors of .
7. If internal routes are not suitable, staff may report externally to the Care Quality Commission, the local authority, the police or the Health and Safety Executive.

Concerns may be raised verbally, in writing or by email. Staff must record factual details in the incident system as soon as practicable. Records must state what was seen or heard, when, where and who was present. They must not include opinion presented as fact.

9.3 Whistleblowing and protection from harm

supports staff who raise concerns in the public interest. The Public Interest Disclosure Act 1998 amended the Employment Rights Act 1996 to protect workers who make a qualifying protected disclosure. Protection applies to employees, agency workers and others covered by the legislation.

• No member of staff will be dismissed, disciplined, bullied, excluded from shifts or treated unfairly for raising a concern in good faith.
• Any act of retaliation will be treated as gross misconduct.
• Staff may ask for their identity to be kept confidential. Managers will keep identity restricted as far as the law and the investigation allow. Staff must be told if confidentiality cannot be maintained.
• Staff may raise a concern anonymously. Anonymous concerns will still be considered, although follow up may be limited.
• Staff may seek independent advice from a trade union, Acas or the whistleblowing charity Protect.
• Staff may report directly to the Care Quality Commission. Staff do not have to use internal routes first.

Deliberately false or malicious reports are not protected and may lead to disciplinary action.

9.4 Investigation procedure

1. The manager who receives the concern records it and acknowledges it to the person who raised it within two working days.
2. The Duty Manager takes immediate action to make people safe. This may include medical attention, removing a hazard or separating individuals.
3. The Registered Manager decides who will investigate. The investigator must be independent of the issue and trained in investigation.
4. The Registered Manager decides whether a safeguarding referral, a Care Quality Commission notification or a police referral is needed. See sections 9, 11 and 14.
5. The investigator gathers evidence. This includes records, rotas, witness accounts, care plans, medicines records and any photographs or equipment checks.
6. The investigator interviews relevant people. Staff may bring a companion to formal interviews.
7. A written report states the findings, root causes, any breach of regulation and recommended actions.
8. The Registered Manager agrees an action plan with named owners and deadlines.
9. The person who raised the concern is told the outcome as far as confidentiality allows. They are also told how to escalate if they remain dissatisfied.
10. Learning is shared with the team. The Registered Manager checks that actions are complete and effective.

Where a concern involves a person we support or their family, the duty of candour applies. See section 6.9. Complaints are handled through the complaints procedure, and learning from them feeds into this policy.

10. Risk Assessment Framework

10.1 Purpose and approach

Risk assessment is the main way meets the requirement under Regulation 12 to assess risks to health and safety and to do all that is reasonably practicable to mitigate them. Assessment must be proportionate, person centred and based on the person’s own goals. Supported living is the person’s home. Risk controls must not remove their rights, choice or independence without lawful justification.

10.2 Risk assessment cycle

1. Identify. Use the pre-admission assessment, referral information, health records, family views, observation and the person’s own account.
2. Analyse. Decide who may be harmed, how, how likely this is and how severe the harm could be.
3. Rate. Use the provider’s likelihood and impact matrix to give a score of low, medium, high or critical.
4. Control. Agree measures that reduce the risk. Consider the hierarchy of controls: remove the hazard, substitute, engineer, change practice, then use equipment or protective measures.
5. Record. Write the assessment in the care plan in plain language. State the control measures, who is responsible and when it will be reviewed.
6. Communicate. Brief all staff before they work with the person. Share relevant information with the person, family, advocate and other agencies, in line with consent.
7. Review. Review at the agreed interval and after any incident, hospital stay, change of health, change of medicines or change of environment.

10.3 Risk domains

Assessments must cover, as relevant to the person:

• medicines, including self-administration and covert administration
• health conditions, such as epilepsy, diabetes, dysphagia, pressure ulcers, falls and nutrition
• behaviours that may challenge, self-harm, and risk to others
• fire safety, including a personal emergency evacuation plan
• moving and handling, equipment and the home environment
• community access, travel, money and online safety
• infection risks, including outbreaks and vaccination status
• exploitation, including financial abuse, cuckooing and radicalisation
• lone working risks for staff, including home visits at night

10.4 Positive risk taking

Where a person chooses a course of action that carries risk, staff must support them to understand the risk. Staff must also consider capacity, record the decision, agree safeguards and review it. Where the person has capacity, their informed choice must be respected. Where capacity is lacking, a best interests decision is made in line with the Mental Capacity Act 2005. Any restriction must be the least restrictive option and must be recorded.

10.5 Escalation of high and critical risks

• Staff must tell the Duty Manager the same shift when a new high risk is identified.
• The Duty Manager informs the Registered Manager within one working day.
• Critical risks require immediate action, an interim risk plan and a review within 24 hours.
• High and critical risks are recorded on the service risk register and discussed at the next governance meeting.

10.6 Service level risk register

The Registered Manager maintains a register covering staffing, medicines, premises, infection control, business continuity and information risks. Each entry shows the risk owner, current controls, residual rating and review date. The register is reviewed monthly and presented to the provider’s leadership team.

11. External Notifications

11.1 Principles

must notify regulators and other bodies promptly, accurately and in the right format. Staff must never delay a notification to complete an internal investigation. The Registered Manager is responsible for making notifications. The Duty Manager must start the process if the Registered Manager is unavailable.

11.2 Care Quality Commission notifications

Under the Care Quality Commission (Registration) Regulations 2009, the provider must notify the Care Quality Commission of certain events without delay. These include:

• the death of a person using the service
• serious injury to a person using the service
• any abuse or allegation of abuse involving a person using the service
• an incident reported to or investigated by the police
• events that stop, or may stop, the service from running safely and properly
• changes to the registered manager, the nominated individual or the provider’s details

Notifications are submitted through the Care Quality Commission provider portal. The notification must state what happened, the actions taken and the people informed. The provider must keep a copy.

11.3 Health and Safety Executive: RIDDOR

The Health and Safety Officer () decides whether an event is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013. Reportable events include:

• deaths and specified injuries to workers
• injuries to workers that lead to more than seven days away from normal work
• diagnosed occupational diseases
• dangerous occurrences, such as a collapse of equipment or a fire that stops work
• injuries to non-workers, including people we support, where the incident arises out of work activity and the person is taken to hospital for treatment

Reports are made online to the Health and Safety Executive. Deaths and specified injuries must be notified without delay. The report must be completed within the legal time limit. A record is kept for at least three years.

11.4 Information Commissioner’s Office

The Data Protection Officer () assesses every personal data breach. If the breach is likely to result in a risk to individuals’ rights and freedoms, the Information Commissioner’s Office must be told within 72 hours of becoming aware. If the risk is high, affected individuals must also be told without undue delay. See section 12.

11.5 Local authority, commissioners and health partners

1. Make a safeguarding referral to the adult safeguarding team when a person is experiencing, or at risk of, abuse or neglect.
2. Tell the commissioning team about serious incidents, safeguarding enquiries, significant staffing shortfalls, outbreaks or any event that affects the delivery of commissioned support.
3. Tell the person’s care manager or social worker about incidents that affect the person’s care and support needs.
4. Tell the integrated care board where an incident involves health care, such as a serious medicines error or a pressure ulcer.
5. Tell the UKHSA health protection team about notifiable diseases and suspected outbreaks.
6. Tell the local authority team responsible for Deprivation of Liberty Safeguards when a person may be deprived of their liberty.

11.6 Police, coroner and other bodies

• Call 999 for any crime in progress, immediate danger or suspicious death.
• Report non-urgent crime to the police through the local police non-emergency number.
• Tell the coroner, through the police or the person’s doctor, about any unexpected, unnatural or unexplained death.
• Tell the person’s next of kin and nominated representative as soon as is appropriate and in line with the duty of candour.
• Tell insurers and the Medicines and Healthcare products Regulatory Agency about faulty equipment or medicines safety issues, where relevant.

11.7 Notification procedure

1. The Duty Manager secures the scene and ensures people are safe.
2. The Duty Manager informs the Registered Manager at once.
3. The Registered Manager decides which notifications apply and records the decision.
4. The notification is made by the named person. The time, method and reference number are recorded.
5. The Registered Manager reviews the record within seven days to confirm all duties have been met.

11.8 Learning from deaths and acting on safety alerts

Regulation 12(2)(e) and Regulation 17 require effective systems to learn from deaths and to act on safety information. This subsection adds to section 11. The Registered Manager () is accountable for both processes.

Learning from deaths

1. After any death of a person we support, the Registered Manager makes the notifications in section 11 and offers support to family, other residents and staff.
2. For an adult with a learning disability, or an autistic adult, notify the death to LeDeR, the Learning from Lives and Deaths programme, through the online system. Tell the integrated care board where required. Notify promptly, and do not wait for the cause of death to be confirmed.
3. Cooperate with the LeDeR reviewer. Provide records, care plans and the views of staff. Share the family’s views, if they agree.
4. Hold an internal review for every death. Look at the care and support given, the timeliness of health referrals, communication, end of life planning and whether the death was expected.
5. Record learning and actions in the action plan. Share learning with the team and, where relevant, the commissioner and health partners.
6. Where abuse or neglect is suspected, follow section 14 and cooperate with any Safeguarding Adult Review or coroner’s inquest.

Acting on safety alerts

The Registered Manager registers to receive Medicines and Healthcare products Regulatory Agency (MHRA) drug safety updates, medical device alerts and recalls, and National Patient Safety Alerts, and nominates a lead and a deputy to monitor them. Follow these steps:

• Log each alert on receipt and on the same day decide whether it applies to any person, medicine or equipment in our services.
• Where it applies, take the action stated by the deadline given. This may include quarantining stock, returning equipment, checking medicines with the pharmacist or changing practice.
• Tell affected staff and, where needed, the person, family and prescriber.
• Record the action taken and the date of completion, or why the alert did not apply.
• The Registered Manager reviews the alert log each month and at the governance meeting.
• Report faulty devices or suspected medicine reactions to the MHRA through the Yellow Card scheme.

12. Information Governance

12.1 Lawful and secure handling of records

Safe care depends on accurate, timely and secure information. handles personal data in line with the UK GDPR, the Data Protection Act 2018 and Regulation 17 on good governance. The Data Protection Officer () advises on compliance. The lawful bases and conditions for processing health and care data are recorded in the record of processing activities.

12.2 Care records

Records must be contemporaneous, factual, legible, signed and dated. They must be written so that a person can read them. Staff must:

• record risk assessments, care plans, daily notes, medicines administration, incidents and consent decisions
• record the time and the person who made each entry
• correct errors by a single line with a signed and dated amendment, never by deletion
• never record opinion as fact or use derogatory language
• complete records before the end of the shift

12.3 Confidentiality and sharing

1. Share information only where there is a lawful basis and a clear need.
2. Share the minimum necessary, with the right people, using secure methods.
3. Seek consent where possible and record it. Information may be shared without consent where the law allows it, for example to prevent serious harm.
4. Follow the Caldicott Principles when handling confidential information.
5. Do not discuss people we support in public places or on social media.
6. Record what was shared, with whom and why.

12.4 Security measures

• Use only approved devices and systems. Use strong passwords and multi-factor authentication where provided.
• Lock screens and paper records when unattended.
• Do not send personal data by personal email or messaging applications.
• Report lost or stolen devices at once.
• Follow clear desk and secure disposal rules.

12.5 Personal data breaches

1. Tell the Duty Manager and the Data Protection Officer at once.
2. Contain the breach, for example by recalling an email or securing a record.
3. Record the facts, the data involved and the people affected.
4. The Data Protection Officer assesses risk and decides on notifications to the Information Commissioner’s Office and to individuals.
5. Review causes and put in place actions to prevent recurrence.

12.6 Individual rights, retention and assurance

People have the right to access their records, request correction and, where the law applies, object to or limit processing. Requests must be passed to the Data Protection Officer on the day they are received. Responses are due within one month. Records are kept and disposed of in line with the Records Management Code of Practice for Health and Social Care. completes the Data Security and Protection Toolkit each year and applies the national data opt-out where it is relevant.

13. Communication Protocols

13.1 Communicating with people we support

Staff must communicate in the way that suits each person. This includes easy read, pictures, signs, assistive technology and interpreters. The Accessible Information Standard applies, so each person’s communication needs must be identified, recorded, flagged and shared with partners. Staff must explain risks, treatment and choices in clear language and check understanding.

13.2 Shift handover

1. Hold a verbal handover at every shift change, supported by a written record.
2. Cover each person’s wellbeing, health changes, medicines given or missed, appointments, incidents and risks.
3. Use a structured format such as SBAR: situation, background, assessment, recommendation.
4. Flag any new or changed risk and any task that is outstanding.
5. The Duty Manager confirms handover is complete and signs the record.

13.3 Escalation of health concerns

Situation	Action
Life threatening emergency, such as choking, unresponsiveness, stroke signs or severe bleeding	Call 999. Start first aid. Tell the Duty Manager as soon as is safe.
Urgent concern that is not life threatening	Call NHS 111 or the GP. Record advice given. Inform the Duty Manager.
Routine health concern	Record it, inform the Duty Manager and arrange a GP or nurse appointment.
Medicines error	Seek clinical advice at once. Follow section 6.3 and section 6.9.
Safeguarding concern	Follow section 14. Inform the Safeguarding Lead.

13.4 Communicating with families, advocates and representatives

• Involve families and representatives where the person agrees or where it is in their best interests.
• Offer access to an independent advocate where a person has substantial difficulty being involved and has no appropriate representative.
• Tell the person and, where appropriate, their family promptly when something goes wrong. Follow the duty of candour.
• Keep a record of each significant conversation.

13.5 Working with professionals and commissioners

• Share relevant information with GPs, community nurses, mental health teams, pharmacists and social workers.
• Use hospital passports, care plans and medicines lists when a person moves between services.
• Send timely updates to the commissioning team as required by the contract.
• Attend reviews and multi-disciplinary meetings and record decisions.

13.6 Out of hours and staff communication

• An on-call manager is available at all times. Staff must know how to reach them.
• Staff must be able to contact the Duty Manager at any time on shift. Lone workers must follow check-in arrangements.
• Team meetings are held regularly and include a safe care and treatment item.
• Learning from incidents and complaints is shared in team meetings, supervision and briefings.

14. Safeguarding Interfaces

14.1 How safe care links to safeguarding

Unsafe care can be neglect or abuse. Regulation 13 requires the provider to protect people from abuse and improper treatment. Safeguarding concerns may arise from medicines errors, poor moving and handling, restrictive practice, missed care, financial abuse or neglect. Staff must always consider whether an incident has a safeguarding element.

14.2 Responding to a safeguarding concern

1. Make the person safe and get medical help if needed.
2. Preserve evidence. Do not clean or move items unless this is needed for safety.
3. Listen. Do not promise confidentiality. Do not ask leading questions.
4. Record what was said or seen in the person’s own words.
5. Tell the Duty Manager and the Safeguarding Lead () at once.
6. The Safeguarding Lead decides on the referral. If the Safeguarding Lead is not available, the Duty Manager or Registered Manager makes the referral.
7. Refer to the adult safeguarding team without delay. Out of hours, use the emergency duty team.
8. Call the police on 999 if a crime has been committed or there is immediate danger.
9. Tell the Care Quality Commission, as set out in section 11.
10. Cooperate with any enquiry under section 42 of the Care Act 2014 and follow the multi-agency procedures of the local Safeguarding Adults Board.

The Care Act principles apply to every enquiry: empowerment, prevention, proportionality, protection, partnership and accountability. Making Safeguarding Personal means asking the person what outcomes they want and respecting their wishes where it is safe to do so.

14.3 Allegations about staff

• Remove or restrict the member of staff from contact with people at risk if needed. This is a neutral act and not a disciplinary finding.
• Inform the Registered Manager at once. If the Registered Manager is the subject, inform the nominated individual.
• Refer to the adult safeguarding team and follow the local arrangements for people in a position of trust.
• If a child may be at risk from the person, refer to the LADO within one working day.
• Consider a referral to the Disclosure and Barring Service where the legal test is met. This applies when an employer dismisses or removes a person from regulated activity because of harm or risk of harm.
• Do not start the disciplinary investigation until the safeguarding enquiry agrees it is safe to proceed.

14.4 Mental capacity, Deprivation of Liberty and restrictive practice

• Assume capacity unless there is evidence to the contrary.
• Where a person lacks capacity for a decision, follow the Mental Capacity Act 2005 and record the best interests process.
• Where care arrangements amount to a deprivation of liberty in supported living, the local authority must seek authorisation from the Court of Protection. Tell the relevant team promptly.
• All restraint, restriction and seclusion must be lawful, proportionate, recorded, reviewed and reported.

14.5 Children and other specific concerns

• Where a child is at risk, for example a child visiting or living with a person we support, refer to the children’s front door. Follow the local children’s procedures and Working Together to Safeguard Children 2026.
• Where a child dies or is seriously harmed, the local safeguarding partnership may carry out a child safeguarding practice review. will cooperate fully.
• Where a person dies or is seriously harmed and abuse or neglect is suspected, the Safeguarding Adults Board may commission a Safeguarding Adult Review under section 44 of the Care Act 2014. The provider will cooperate.
• For domestic abuse, refer to the local domestic abuse service and consider a risk assessment and police referral.
• For radicalisation concerns, contact the local Prevent lead.
• For modern slavery, call the Modern Slavery and Exploitation Helpline on 08000 121 700, available 24 hours a day. The provider is not a First Responder for the National Referral Mechanism. An adult must consent to a referral unless a legal duty applies. Concerns about labour exploitation may also be reported to the Fair Work Agency.

15. Related Policies

This policy must be read with the following policies and procedures. Staff must follow the most protective requirement where two documents overlap.

• Safeguarding Adults Policy
• Safeguarding Children Policy
• Medicines Management Policy
• Infection Prevention and Control Policy
• Mental Capacity Act and Deprivation of Liberty Policy
• Positive Behaviour Support and Restrictive Practice Policy
• Duty of Candour Policy
• Incident and Accident Reporting Policy
• Complaints and Compliments Policy
• Whistleblowing Policy
• Health and Safety Policy, including Fire Safety and Lone Working
• Moving and Handling Policy
• Data Protection and Confidentiality Policy
• Records Management and Retention Policy
• Business Continuity and Emergency Planning Policy
• Consent Policy
• Nutrition, Hydration and Dysphagia Policy
• Safer Recruitment and Disciplinary Policy
• Training, Supervision and Appraisal Policy
• Equality, Diversity and Human Rights Policy

Supporting documents include the risk assessment templates, the service risk register, the personal emergency evacuation plan template, the handover record and the notifications log.