You are here:

Safeguarding Policy

Safeguarding Policy

Safeguarding Adults Policy & Procedure

Last Updated: August 2026
Policy Owner: Head of Compliance & Policy

1. Introduction

The Royal Hospital Chelsea’s aim in implementing this policy is to ensure that staff understand their responsibilities in relation to safeguarding and the protection of In-Pensioners from any form of abuse, thus enabling them so to live in a safe and non-threatening environment, free of any abuse.

1.1 Policy Statement 

Royal Hospital Chelsea has a legal responsibility to protect adults from abuse, harm or neglect (including self-neglect) and to act positively to report concerns.

We will take all reasonable steps to prevent harm, to protect people and to respond appropriately when harm does occur.

2. Training and Support 

All RHC staff, commissioners and volunteers will be made aware of the Safeguarding policy at corporate induction and be presented with an overview.

All staff and Commissioners are required to undertake an online annual level 1 safeguarding training.  

All care staff are required to have accredited level 2 safeguarding training. 

Clinical Managers are required to have accredited level 3 safeguarding training. 

Non-clinical managers are required to have equivalent level 3 safeguarding training, delivered by the Social Care Institute for Excellence. 

The designated safeguarding lead is required to be trained to safeguarding level 4.

All staff need to recognise that safeguarding is everyone’s responsibility, irrespective of the role they undertake. 

2.1 Scope

This policy and the procedures apply to all staff, including workers and independent sub-contractors.

Royal Hospital Chelsea are required to have a Safeguarding Lead responsible for guiding and supporting staff when dealing with the safeguarding of adults. 

Safeguarding Lead: Director of Health and Wellbeing, Dr Jeremy Tuck. In the absence of the Director of Health & Wellbeing the Safeguarding Lead is the Head of IP Welfare. 

There is an additional policy Safeguarding Adults Policy – RHC Care Home, which gives further detail on Safeguarding IPs living in the RHC Care Home. 

3. Policy

The RHC Safeguarding Adults Policy puts into place procedures to ensure that appropriate checks are made prior to appointment of staff and volunteers, in order to prevent, as far as practicable, anyone from using their position to carry out abuse. 

The RHC ensure that all IPs, or others on their behalf, are actively encouraged to provide feedback on the service they receive and take any comments or complaints seriously. 

The RHC has a Safeguarding Board which meets twice a year, it was established to create a coordinated approach to safeguarding across the organisation. As detailed in its Terms of Reference, the Safeguarding Board publishes an annual strategic action plan setting out the organisation’s safeguarding objectives for the year ahead and an Annual Report reviewing progress. The Safeguarding Board reports to the Commissioners’ Board via the Health and Wellbeing Oversight Committee (HWOC). There is also a Safeguarding Board sub-group who meet twice a year to track progress on the action plan. 

The Safeguarding Board has delegated responsibility from the Executive Board and is accountable to the Health & Wellbeing Oversight Committee (HWOC). 

The RHC has a safeguarding lead, who provides a one-stop point of contact for addressing initially all safeguarding concerns in the service and in corresponding and communicating with external agencies, particularly the local authority adult safeguarding team. The current Safeguarding Lead is the Director of Health & Wellbeing – Dr Jeremy Tuck.

In addition to Dr Tuck, the Head of Welfare (Ms Jo Molendo) and the Head of Nursing/Matron/Registered Manager (Ms Monika Balciunaite) act as the day to day case managers for any safeguarding issues that affect either the general campus (including residents and visitors (Ms Molendo)) the Long Wards (The In Pensioners residencies (Ms Molendo) or the Registered areas (Ms Balciunaite). In discussion with the designated safeguarding lead, they will lead on escalating safeguarding concerns to the Local Authority safeguarding teams and monitoring progress on any investigations and taking the lead in generating any formal returns that the Local Authority Safeguarding Teams need.  

The RHC recognises that safeguarding involves a range of responses to different forms of abuse and potential sources of harm and the different contexts in which abuse occurs. 

Key Personalities

The Chief Executive, The Director of Health and Wellbeing, the Head of Welfare and the Head of Nursing/Matron/Registered Manager are the three key stakeholders concerning the leadership and management of safeguarding issues within the Royal Hospital.

  • The Chief Executive.   The Chief Executive (Mr David Richmond) is the Responsible Officer for the Royal Hospital Chelsea and has overall responsibility for the totality of the activity that takes place in the Royal Hospital. However, he requires the support of specialist advisers who can advise on necessary actions and take the day to day lead for all safeguarding matters at the Royal Hospital.
  • The Designated Safeguarding Lead.   The Designated Safeguarding Lead for the Adults and, Children and Young People, is the Director of Health and Wellbeing. They are required to have a professional, regulated background for example Doctor, Nurse, Allied Health Professional or Social Worker. Other individuals from professionally regulated careers (lawyers, dentists, priests, teachers) or the uniformed, disciplined services might apply for the role but would have to show particular experience and expertise in safeguarding to quality for consideration.
  • The Head of Welfare.   The head is the lead, amongst other things, for delivery of the social work function at the Royal Hospital. Professional regulation is not mandatory for this role but knowledge, experience and skill in safeguarding are required.
  • Head of Nursing/Matron/Registered Manager.   The Head of Nursing, by virtue of being the Registered Manager, is the lead for making mandatory reports to the CQC including safeguarding incidents. The post holder must, therefore, show real life experience of managing safeguarding issues in order to be considered for the role.

What is adult safeguarding?

Safeguarding, as defined by SCIE is: 

Protecting an adult’s right to live in safety, free from abuse and neglect. It is about people and organisations working together to prevent and stop both the risks and experience of abuse or neglect, while at the same time making sure that the adult’s wellbeing is promoted including, where appropriate, having regard to their views, wishes, feelings and beliefs in deciding on any action. This must recognise that adults sometimes have complex interpersonal relationships and may be ambivalent, unclear or unrealistic about their personal circumstances.

Policy & Procedure Aims

The RHC works on the principle that it is the right of In-Pensioners to be kept safe from all forms of abuse/harm. Being and feeling safe will contribute a great deal to their wellbeing and quality of life. It therefore recognises that it must at all times protect its In-Pensioners and identify and deal with specific instances of abuse/harm if they occur, following the required procedures and best practice guidance.

As a part of our commitment, Royal Hospital Chelsea will adhere to the 6 key principles of safeguarding outlined in the Care Act 2014:

Empowerment - Empowerment is the principle that adults should be in control of their lives and consent is needed for decisions and actions designed to protect them.

Prevention - Safeguarding adults procedures provide a framework by which adults can be supported to safeguard themselves from abuse, or are supported and protected, where they are unable, for reasons of mental capacity, to make decisions about their own safety.

Proportionality - Prevention of abuse is the primary goal, and members of the public, agencies, service providers, individual employees or volunteers and communities all have a role in preventing abuse from occurring. Prevention involves promoting awareness and understanding and supporting people to safeguard themselves from the risk of abuse. This includes helping people to identify and make informed decisions about risks and develop forward plans that keep them safe.

Protection - The principle of proportionality relates to the responsibility to ensure that responses to safeguarding concerns are proportional to assessed risk and the nature of the allegation/concern. Proportionate decisions need to take into account the principles of empowerment and protection.

Partnership - Partnership means working together to prevent and respond effectively to incidents or concerns of abuse, to support the adult at risk in making informed decisions about identified risks of harm and helping them to access sources of support that keep them safe.

Accountability - The principle of accountability involves transparency and decision making that can be accounted for. This involves each individual and Company fulfilling their duty of care, making informed defensible decisions, with clear lines of accountability. It involves companies, staff (and volunteers) understanding what is expected of them, recognising and acting upon their responsibilities to each other, and accepting collective responsibility for safeguarding arrangements.

The RHC takes every possible action to prevent abuse/harm and associated risks and to deal with the issues as promptly and effectively as possible when they arise.

We seek to work in line with local safeguarding adults’ authority policies and procedures. We recognise the importance of government and national guidance and seeks to comply in all respects with current safeguarding legislation and regulations.

The RHC recognises that In-Pensioners who lack mental capacity are particularly vulnerable to abuse/harm and exploitation. It is accordingly mindful of the need to follow the principles and practice guidance that has accompanied the Mental Capacity Act 2005. 

The RHC has all required systems in place to track and monitor incidents, accidents, disciplinary action, complaints and safeguarding concerns, and to identify patterns of potential abuse/harm to its In-Pensioners.

What is abuse? 

Abuse is the violation of an individual’s human and civil rights. Abuse can be self-inflicted or inflicted by another person or persons. In the context of safeguarding, it is used to refer to any knowing, intentional or negligent act by another that causes harm or a serious risk of harm to another. The Care Act recognises ten categories of abuse experienced by adults as follows, although it is important to also recognise that cyber bullying, forced marriage, mate crime and radicalisation can also apply to adults: 

  • actual physical abuse/harm - including assault, hitting, slapping, pushing, misuse of medication, restraint or inappropriate physical restraint.
  • social abuse - including bullying, cyberbullying, harassment and personal exploitation, social isolation/scapegoating/ostracism/stigmatisation. 
  • financial or material exploitation/abuse/harm - including theft, fraud, internet scamming, coercion in relation to an adult’s financial affairs or arrangements, including in connection with wills, property or inheritance or financial transactions, or the misuse or misappropriation of property, possessions or benefit.
  • psychological or emotional abuse/harm - including threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse or isolation.
  • sexual abuse/harm/exploitation - including rape, indecent exposure, sexual harassment, inappropriate looking or touching, sexual teasing or innuendo, sexual photography, subjection to pornography or witnessing sexual acts.
  • neglect and acts of omission - including ignoring medical, emotional or physical care needs or a failure to provide access to appropriate health, care and support or educational services and/or the withholding of necessities of life, such as medication, adequate nutrition and heating.
  • discriminatory abuse/harm - including forms of harassment, slurs or similar treatment, because of race, gender and gender identity, age, disability, sexual orientation or religion.   
  • self-harm, including self-neglect - this covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding.
  • inhuman or degrading treatment
  • inappropriate or excessive restraint and restrictions on movement and activities
  • organisational abuse/harm - including neglect and poor care practice within an institution or specific care setting such as a hospital or care home, for example, or in relation to care provided in one’s own home.

The RHC recognises that situations are rarely as tidy or straightforward as these categories suggest. Many situations may involve a combination of abusive elements. 

The Role and Responsibilities of Royal Hospital Staff in relation to adult safeguarding: 

The Safeguarding Lead for Adults and, Children and Young People (Director of Health & Wellbeing (Dr Jeremy Tuck)) has a responsibility to: 

  • managerial support and direction to staff at the Royal Hospital
  • decision making for concerns raised by members of staff and/or members of the public.
  • chair the Royal Hospital Safeguarding Board and producing an annual strategic plan for the organisation.
  • develop the systems and structures within which it is possible to deliver the best possible care and welfare support to In-Pensioners
  • develop the systems and structures to ensure that information and support is accessible to help members of the Royal Hospital community to understand the different types of abuse, how to stay safe and what to do to raise a concern about the safety or wellbeing of an In-Pensioner; and
  • develop the systems and structures so that the Royal Hospital community as a whole, alongside other professionals, play a part in preventing, identifying and responding to abuse and neglect; 
  • produce and regularly review the policies and procedures designed to prevent and deal with abuse/harm, in accordance with the Care Act (2014)
  • review investigations undertaken by designated investigators to ensure they are appropriate where there is any evidence or suspicion of abuse or neglect 
  • implement improvements to procedures if an investigation into abuse or neglect reveals deficiencies in the way in which the Royal Hospital operates
  • collaborate with other relevant agencies in combating abuse and neglect and improving the safeguarding and protection of those with care and support needs.
  • liaise with the local safeguarding adults team and seek the guidance and instructions of the bi-borough Safeguarding Adults Board, particularly around the coordination of multi-agency working. 

In the absence of the Director of Health & Wellbeing the Safeguarding Lead is the Head of IP Welfare (Ms Jo Molendo))

The Head of Nursing/Matron/Registered Manager and Head of IP Welfare have the responsibility to: 

  • Log and investigate all Safeguarding concerns in the registered area (Head of Nursing) and non-registered area (Head of IP Welfare). 
  • ensure that all evidence, documents, and lessons learned from investigations are stored and maintained, as required in the centralised files on Sharepoint
  • Ensure that lessons learnt from safeguarding concerns raised are documented centrally to allow for greater transparency and organisational knowledge sharing.
  • collaborate with other relevant agencies in combating abuse and neglect and improving the safeguarding and protection of those with care and support needs.
  • liaise with the local safeguarding adults team and seek the guidance and instructions of the bi-borough Safeguarding Adults Board, particularly around the coordination of multi-agency working.

All Royal Hospital staff members and volunteers have a responsibility to: 

  • provide all In-Pensioners with the best possible care
  • desist from any abusive / neglectful action in relation to In-Pensioners or other visiting adults
  • report anything they witness which is or might be abusive/neglectful
  • co-operate in every possible way in any investigation into alleged abuse or neglect
  • participate in training activities relating to the safeguarding policy.

What is a safeguarding concern? 

An adult safeguarding concern is any worry about an adult who has or appears to have care and support needs, that they may be subject to, or may be at risk of, abuse and neglect and may be unable to protect themselves against this. The adult does not need to be already in receipt of care and support. 

A concern may be raised by anyone, and can be: 

  • An active disclosure of abuse by the In-Pensioner or other adult, where they tell a member of staff / volunteer that they are experiencing abuse and/or neglect; 
  • A passive disclosure of abuse where someone has noticed signs of abuse or neglect, for example clinical staff who notice unexplained injuries; 
  • An allegation of abuse by a third party, for example a family member or friend or fellow In-Pensioner who have observed abuse or neglect or have been informed of it; 
  • A complaint or concern raised by an In-Pensioner or a third party who does not perceive that it is abuse or neglect. Line managers should consider whether there are safeguarding matters;
  • A concern raised by a staff member or volunteer, another In-Pensioner, family member or friend. 
  • An observation of the behaviour of the adult at risk; 
  • An observation of the behaviour of another; 
  • Patterns of concerns or risks that emerge through reviews, audits and complaints or regulatory inspections or monitoring visits (e.g. CQC). 

What to in the event of a concern

All staff and volunteers have a duty of care to report any incidents or suspicions they have about abuse or neglect, as not to do so, may have a negative impact on the wellbeing of the In-Pensioner and allow the abuse or neglect to continue. 

If staff or anyone else thinks there may be a safeguarding concern, they must take action. Decisions can only be made after the concern has been properly looked into

Your responsibilities when you have safeguarding concerns (see Appendix 3): 

  • Assess the situation. (Is the individual in immediate danger? Are the emergency services required?)
  • Ensure the safety and wellbeing of the individual (prevent further harm if possible)
  • Establish what the individual’s views and wishes are about the safeguarding issue and procedure 
  • Maintain any evidence
  • Remain calm and try not to show any shock or disbelief
  • Listen carefully and demonstrate understanding by acknowledging the concern
  • Inform the person that you are required to share the information, explaining what information will be shared and why 
  • Make a written record of what the person has told you, using their words or what you have seen as well as your actions. 
  • Report the concern/incident to your line manager as soon as possible.

What happens next? 

When a safeguarding concern has been raised, the line manager/safeguarding lead will usually lead on decision making. When this is not possible, consultation with the most senior staff member in your area should take place. In the event that these are unavailable, seeking the advice of the Local Authority should be considered. 

Staff should also take action without the immediate authority of a line manager if: 

  • a discussion with the manager would involve delay in an apparently high-risk situation; 
  • the person has raised concerns with their manager and they have not taken appropriate action (whistleblowing). 

When a safeguarding concern has been raised, the line manager/safeguarding lead will: 

  1. Speak directly to the adult who is known or suspected to have been abused/neglected and identify their wishes and feelings about the situation and the potential course of action to be taken. If there is a concern the that the adult concerned might lack mental capacity or have fluctuating capacity at the time of the incident, an assessment to establish their capacity should be undertaken in line with the principles of the Mental Capacity Act (2005) and any decisions taken in their ‘best interests’ (see In-Pensioners Who Lack Mental Capacity to Take Decisions Policy). 
  2. Ensure that there is appropriate action taken to provide protection, support or additional care, as required, to the individual concerned, in accordance with their wishes. 
  3. Speak to any witnesses to clarify the situation and take further initial statements. 
  4. Support the reporting staff member to complete an Accident/ Incident reporting form and also complete an Accident/Incident report on Kare Inn.
  5. Seek to establish the facts as far as possible via an initial internal investigation.

If it is clear that abuse has not taken place, the line manager/safeguarding lead will address any other remaining issues – for example, there may be a personality clash between a staff member and In-Pensioner, or an underlying quality of care issue – and close the investigation by completing and signing Part B of the incident form and logging appropriately (including adding details to Kare Inn). The incident and written report, with identified outcomes will also be presented at the next Safeguarding Board to ensure the actions taken were appropriate and so that lessons may be learned to prevent future occurrences of abuse/neglect. 

If the initial investigation indicates that abuse has or may have occurred, the line manager/safeguarding lead will assess the actions they consider to be appropriate and discuss these with the individual concerned. Advice on the correct action to be taken can be sought from the RBKC social services team (see Appendix 1 for contact details).

Decisions need to take into account all relevant information that is available, including the views of the individual in all circumstances where it is possible and safe to seek their views. If the individual does not want to pursue matters through safeguarding action, the line manager/safeguarding lead should be sure that they are fully aware of the consequences of their decisions, and that all options have been explored and that not proceeding further is consistent with legal duties. 

The line manager/safeguarding lead may consider whether there are reasons for overriding the wishes of the individual concerned while ensuring their wellbeing is fully considered within any safeguarding arrangements, in line with the guidance on least restrictive actions.

Making a Referral to the Royal Borough of Kensington & Chelsea (RBKC) (the Local Authority)

If, on the basis of the information available, it appears that the following three steps are met, then a referral must be made to RBKC (the Local Authority): 

  • The In-Pensioner/ adult has care and support needs
  • They may be experiencing or at risk of abuse and neglect
  • They are unable to protect themselves from that abuse and neglect because of those care and support needs

A referral can be made by contact the Safeguarding Adults team (see Appendix 1 for contact details) or by completing the Kensington and Chelsea Safeguarding Alert Form (Appendix 4).

Where the In-Pensioner at risk does not want to pursue a referral to the Local Authority, these wishes should be respected, if possible, and other ways of ensuring their safety explored. 

The line manager/safeguarding lead also need to take account of whether or not there is a public or vital interest to refer the concern to the Local Authority. Where there is a risk to other adults, children or young people or there is a public interest to take action because a criminal offence had occurred and the view is that it is a safeguarding matter, the wishes of the individual may be overridden. Where the sharing of information to prevent harm is necessary, lack of consent to information sharing can also be overridden. 

If the alleged abuser is a staff member, they will be instructed not to have further unsupervised contact with any In-Pensioners until the matter is resolved or, if there is sufficient evidence that abuse/harm has or might have occurred, the staff member will be suspended from duty (on full pay, if appropriate).  If the abuser involves an agency staff member, the agency will be informed, and the individual will not be requested to cover agency shifts. 

If the alleged abuser is a volunteer or outside visitor, they will be prevented from entering the Royal Hospital grounds pending the outcome of an investigation. 

If the alleged abuser is an In-Pensioner, they will be separated from the victim – and, if required, from other In-Pensioners. The priority for the Royal Hospital will always strive to keep a victim safe from further abuse/neglect, in accordance with the individual’s wishes. In instances when an In-Pensioner wants to continue to have contact with the adult who is the alleged abuser, and has the capacity to make this decision, then alternative ways to keep them safe should be explored. 

The Head of Nursing will notify the CQC of any alert raised with the local safeguarding authority under its Outcome 20 procedure for all In-Pensioners within the regulated activities. 

Where a crime is suspected

If the suspected or alleged abuse might also be a criminal offence, the matter will be passed directly to the Police, if it has not already been reported. The police investigation will take precedence and the Royal Hospital will seek their guidance on the measures to be taken. 

Investigating alleged abuse in line with Local Authority guidance 

As outlined in Section 42 of the Care Act (2014), the Local Authority (RBKC) has a statutory duty to oversee a safeguarding adults’ enquiry.

Where the circumstances are not such as to trigger the Section 42 safeguarding duty, the Local Authority may choose to carry out proportionate safeguarding enquiries, in order to promote the In-Pensioner’s wellbeing and to support preventative action. An enquiry should establish whether and what action needs to be taken to prevent or stop abuse or neglect. 

The Local Authority should aim to provide a swift and personalised safeguarding response, involving the In-Pensioner at risk in the decision-making process as far as possible. The Local Authority will decide who the best person/organisation to lead the enquiry is. 

The guidance received following the Local Authority, will advise on the steps to be taken by the Royal Hospital from that point on.

The information in some referrals made to the Local Authority may be sufficiently comprehensive that it is clear that immediate risks are being managed, and that the criteria are met for a formal Section 42 enquiry. 

In other cases, some additional information gathering may be needed. Decisions need to take into account all relevant information through a multi-agency approach wherever possible, including the views of the In-Pensioner taking into consideration mental capacity and consent. 

The degree of involvement of the Local Authority will vary from case-to-case but, at a minimum, must involve decision-making about how the enquiry will be carried out, oversight of the enquiry, decision-making at the conclusion of the enquiry about what actions are required, ensuring data collection is carried out, and quality assurance of the enquiry has been undertaken. 

This decision on how the enquiry is progressed is made by the line manager/safeguarding lead.

In cases where a member of Royal Hospital staff is appointed as the Safeguarding Enquiry Officer, the following procedure will be adopted: 

  1. The In-Pensioner will be involved in line with their wishes.
  2. Throughout the investigation, full consideration will be given to:
    1. the fears and sensitivity of the individual at risk
    2. any risks of intimidation or reprisals
    3. the need to protect and support witnesses
    4. any confidentiality or data protection issues in line with GDPR.
    5. the involvement of other agencies, including the Police, Local Authority safeguarding team and the CQC for the regulated activities
    6. the obligation to keep the adult at risk and, in specific instances, the alleged perpetrator informed on the progress of the investigation.
  3. The Royal Hospital Chelsea will assure the In-Pensioner who may have been abused/neglected that they will be taken seriously, that the comments will as far as possible be treated confidentially, that they will be protected from reprisals and intimidation, and that they will be kept informed of actions taken and of the outcome.
  4. The Safeguarding Enquiry Officer will consider whether the In-Pensioner needs independent help or representation in presenting their evidence and will arrange for the appropriate help or support to be made available.
  5. If the In-Pensioner who has been abused/harmed person expressly states a wish that no further action should be taken, the Investigating Officer will consider whether:
    1. there is a danger to others from not investigating further
    2. in the light of that assessment it is possible to follow the person’s wishes
    3. in any case precautionary measures should be taken to protect others from the possibility of abuse from the same source.
  6. If it is decided that an investigation should proceed, the Safeguarding Enquiry Officer will inform the In-Pensioner of what is to happen and, as discreetly and confidentially as possible, look into all aspects of the situation.
  7. The enquiry will include interviewing the staff/volunteers involved in the incident up to that point, hearing and assessing evidence from any others who might be in a position to supply information, exploring every other possible source of evidence, maintaining appropriate contact with any other agencies involved and, if necessary, seeking expert advice on any technical aspects of the situation which are outside the knowledge or expertise available within the organisation.
  8. Staff members who provide evidence are assured that they will be dealt with in a fair and equitable manner and informed of their employment, legal and procedural rights.
  9. The alleged victim of the abuse/neglect, and where appropriate their relatives, friends or representatives, will at all times be kept as fully informed as possible of what is happening regarding the suspected abuse/neglect.
  10. The investigation will be carried out as quickly as possible and the findings presented to the RBKC safeguarding adults strategy group, which will then decide what further action to take.

Following the investigation

If the investigation determines that abuse/neglect has taken place, swift and appropriate actions will be taken depending on the source of abuse. 

  1. If abuse/neglect is proved against a Royal Hospital Chelsea staff member:

The Chief Executive Officer will ensure that proceedings according to the Royal Hospital Chelsea's disciplinary policy are followed, which most likely will be dismissal and referral to the Disclosure and Barring Service (DBS) to prevent them from being employed further in regulated activity. Other employment sanctions could apply depending on whether there might have been mitigating or extenuating circumstances and, in some cases, retraining could be appropriate.

  1. If abuse/neglect is proved against an agency staff member:

The relevant department head will inform the agency of the findings of the investigation and, in conjunction with the agency concerned (e.g. Prospects), the individual may be referred to the Disclosure and Barring Service (DBS) to prevent them from future employment in regulated activity. Other employment sanctions could apply depending and, in some cases, the agency may decide retraining is appropriate. At a minimum, the Royal Hospital will not use the agency worker again. 

  1. If abuse/neglect is proved against an individual working for an external contractor (e.g. CBRE or Wilson James):

The Director of Health & Wellbeing in conjunction with the Quartermaster (if applicable) will inform the organisation of the findings of the investigation and, in conjunction with the organisation concerned, the individual may be referred to the Disclosure and Barring Service (DBS) to prevent them from future employment in regulated activity. Other employment sanctions could apply depending and, in some cases, the organisation may decide retraining is appropriate. At a minimum, the Royal Hospital will not use the worker again. 

  1. If abuse/neglect is proved against a volunteer

The volunteer will be dismissed from their duties, asked to return their RHC name badge and identity card, and prevented from future access to the Royal Hospital Chelsea.

  1. If abuse is proved against another In-Pensioner

While every effort will be made to resolve and prevent peer-to-peer bullying behaviour between In-Pensioners, no form of bullying or abuse of an In-Pensioner by another In-Pensioner will be tolerated at the Royal Hospital Chelsea. 

The priority for the Royal Hospital is always to keep a victim safe from further bullying. Therefore, in situations where a perpetrator of abuse is also a Chelsea Pensioner, the Director of Health & Wellbeing (Safeguarding Lead) will review and investigate any requirement to terminate an In-Pensioner’s right to remain at the Royal Hospital.

  1. If the abuser is none of the above (e.g. visitor, family member)

The Royal Hospital will take action to involve other responsible bodies, such as the Police, and, with the In-Pensioner’s consent, prevent the individual from entering the Royal Hospital Chelsea grounds. 

  1. In situations of self-neglect, advice, support and referral to appropriate agencies will be actioned, in line with the principles of the Mental Capacity Act (2005). In instances when an In-Pensioner continues with self-neglectful behaviour, and has the capacity to make this decision, then alternative ways to keep them safe should be explored. 

The In-Pensioner and/or representatives will be informed of the outcome of the investigation and any further action and will be consulted about whether any redress or apology would be appropriate and helpful to them.

At all stages, a careful record of all actions taken is kept and particular attention to the sensitivity of the abused/neglected person.

Where criminal procedures are conducted without action being taken, this does not automatically mean that regulatory or disciplinary procedures should cease or not be considered.  Therefore, following the closure of a Police investigation, particularly without action being taken, an internal investigation will follow with subsequent action by the Royal Hospital taken.   

Review of incidents

At the end of an incident involving possible or actual abuse/neglect, a review of what has happened will be undertaken to assess whether the organisation or its management has been in any way culpable, ineffective or negligent, to learn lessons for the future. In particular, serious untoward incident reports are presented to the Health & Wellbeing Oversight Committee (HWOC) on a quarterly basis for discussion and review as well as discussion at the Executive Board, if appropriate. 

The RHC Safeguarding Board will review all incidents to ensure that appropriate lessons are learnt to reduce the likelihood of further occurrences of abuse or harm to In-Pensioners. 

If required, Royal Hospital Chelsea policies, procedures and training arrangements will be modified in response to any material that has emerged from the incident or the investigation. In particular, any advice and guidance from the RBKC Adults’ Safeguarding Board will be followed.

Duty of Candour 

The Royal Hospital values openness and transparency and will fully inform the In-Pensioner(s) – or visiting adults – concerned of any mistakes which have or may have led to a safeguarding incident. The Royal Hospital will also seek the consent of the In-Pensioner(s) concerned to inform their next of kin – or will do so in their best interests following an assessment of capacity – after any incident.

The Royal Hospital will follow the procedures outlined in our Duty of Candour Policy in situations where our statutory duty of candour applies, i.e. where the incident:   

a. appears to have resulted in: 

  1. the death of the In-Pensioner, where the death relates directly to the incident rather than to the natural course of the In-Pensioner’s illness or underlying condition,
  2. an impairment of the sensory, motor or intellectual functions of the In-Pensioner  which has lasted, or is likely to last, for a continuous period of at least 28 days,
  3. changes to the structure of the In-Pensioner’s body,
  4. the In-Pensioner experiencing prolonged pain or prolonged psychological harm, or
  5. the shortening of the life expectancy of the In-Pensioner;
  6. or requires treatment by a health care professional in order to prevent:

a. the death of the In-Pensioner, or
b. any injury to the In-Pensioner which, if left untreated, would lead to one or more of the outcomes’ described in (a) above.

Record Keeping

The Royal Hospital ensures that all details associated with allegations of abuse/neglect are recorded clearly and accurately. The records are kept securely and the Royal Hospital’s rules on confidentiality are carefully followed. Reports are made as required to the CQC and other safeguarding agencies involved.

Referrals to DBS Barred Lists

The Royal Hospital will always comply with its legal requirement to make a referral to the DBS barred lists where it has evidence that the staff member in question has been guilty of misconduct by harming or putting at risk of harm an In-Pensioner or other person at risk.

Related Policies

This policy should be read in conjunction with the several other policies of the Royal Hospital that relate to safeguarding of In-Pensioners, including complaints, supporting In-Pensioners to manage their money, mental capacity and whistleblowing. 

Review 

This policy requires a yearly review. 

Next review date: March 2027/As required

  1. Relevant Legislation