Inclusion criteria
- •Any patient with a documented safeguarding concern raised during the audit period
- •Concerns relating to children and young people under 18
- •Concerns relating to adults with care and support needs under the Care Act 2014
- •Concerns involving domestic abuse, exploitation, modern slavery, radicalisation and self-neglect
- •Cases identified in inpatient, ED, outpatient, community, mental health and maternity settings within scope
- •Electronic, paper or hybrid records depending on local setup
Exclusion criteria & limitations
- •Cases where no safeguarding concern was raised or documented
- •Cases outside the selected audit period
- •Duplicate concerns or duplicate records for the same episode
- •Records unavailable for review
- •Cases where the local safeguarding lead has requested exclusion from routine audit
- •Cases where governance approval is required but has not been obtained
- •Direct patient identifiers must not be entered into the tool
Audit criteria (31)
Aligned with Working Together to Safeguard Children (2023), the Care Act 2014, NICE NG76, the Intercollegiate Safeguarding Competency Frameworks and the Mental Capacity Act 2005. Compliance is calculated using Yes and No responses only; Not applicable and Unable to determine are excluded from the denominator.
- C1Safeguarding concern clearly documented in the clinical record.Target ≥ 95% · auto-computed from submissions
- C2Concern documented within the locally agreed timeframe of identification.Target ≥ 95% · auto-computed from submissions
- C3Type of safeguarding concern (child, adult or both) clearly identified.Target ≥ 95% · auto-computed from submissions
- C4Category of concern documented (physical, sexual, emotional, neglect, financial, domestic abuse, exploitation, self-neglect, mental-health-related or other).Target ≥ 95% · auto-computed from submissions
- C5Chronology of events documented factually and objectively.Target ≥ 90% · auto-computed from submissions
- C6Patient / child voice documented in their own words where possible.Target ≥ 90% · auto-computed from submissions
- C7Physical findings documented objectively (body maps where appropriate).Target ≥ 90% · auto-computed from submissions
- C8Household / dependants / siblings considered and documented where relevant.Target ≥ 90% · auto-computed from submissions
- C9Risk assessment completed and documented.Target ≥ 95% · auto-computed from submissions
- C10Immediate safety plan documented where risk identified.Target ≥ 95% · auto-computed from submissions
- C11Named safeguarding lead / named doctor / named nurse notified.Target ≥ 95% · auto-computed from submissions
- C12Notification documented with time, date and named person.Target ≥ 90% · auto-computed from submissions
- C13External referral to Local Authority / MASH made where indicated.Target ≥ 95% · auto-computed from submissions
- C14Referral documented with reference number or acknowledgement.Target ≥ 90% · auto-computed from submissions
- C15Police involvement considered and documented where applicable.Target ≥ 90% · manual review
- C16Mental Capacity Assessment completed where relevant (adult).Target ≥ 90% · auto-computed from submissions
- C17Capacity documented with rationale where MCA required.Target ≥ 90% · auto-computed from submissions
- C18Best-interests decision documented if the adult lacks capacity.Target ≥ 90% · manual review
- C19Consent and information sharing discussed and documented.Target ≥ 90% · auto-computed from submissions
- C20Information-sharing rationale documented (Caldicott / vital interests).Target ≥ 90% · auto-computed from submissions
- C21Making Safeguarding Personal principles applied (adult).Target ≥ 90% · auto-computed from submissions
- C22Child Protection Plan / Child in Need status checked (child).Target ≥ 90% · auto-computed from submissions
- C23Multidisciplinary discussion / safeguarding huddle documented.Target ≥ 85% · auto-computed from submissions
- C24Follow-up / reassessment plan documented.Target ≥ 90% · auto-computed from submissions
- C25Discharge safety plan documented where relevant.Target ≥ 90% · auto-computed from submissions
- C26Communication with GP / community teams / school nurse / health visitor documented.Target ≥ 85% · auto-computed from submissions
- C27Outcome of safeguarding action documented and closed out.Target ≥ 90% · auto-computed from submissions
- C28Any escalation or safety concern actioned appropriately and in a timely manner.Target ≥ 100% · auto-computed from submissions
- C29Documentation is clear enough for another clinician or safeguarding lead to understand the concern and plan.Target ≥ 90% · manual review
- C30Records are contemporaneous, legible, dated, timed and signed with role/grade.Target ≥ 95% · manual review
- C31Documentation meets local safeguarding policy and statutory expectations.Target ≥ 90% · manual review