Safeguarding adults in care homes: types of abuse, signs and how to report a concern

Safeguarding adults in care homes means protecting people with care and support needs from abuse and neglect, and doing it in a way that respects their own wishes. The legal duty sits with the local authority under sections 42 to 47 of the Care Act 2014, but the people who see the first signs are your care staff, and the person who decides whether a concern is raised is you. This guide sets out the ten types of abuse in the statutory guidance, the signs to look for in a residential, nursing, learning disability or mental health home, and the reporting route from the care worker on shift to the local authority, the police and CQC.

The short answer

If a member of staff sees, hears or suspects abuse or neglect, they report it to the person in charge straight away, make sure the resident is safe, and write down what they saw in their own words. The manager decides the same day whether the concern meets the threshold for a referral to the local authority safeguarding team, and in most cases the answer is to refer and let the local authority decide. Serious harm or a crime also goes to the police, and any allegation of abuse must be notified to CQC. Ask the resident what they want to happen, record their wishes, preserve any evidence, and keep a safeguarding log that shows every concern, every decision and every outcome. Then look for patterns, because one concern is an event and three are a culture.

What is safeguarding in care

People searching for what is safeguarding in care usually want a definition they can use in an induction. Here is one: safeguarding is protecting an adult's right to live in safety, free from abuse and neglect, while respecting their views and their right to make their own choices. The statutory guidance to the Care Act adds that it means people and organisations working together to prevent and stop the risks of abuse or neglect, and it makes clear that safeguarding is not a substitute for good care, effective complaints handling, or the wider work of protecting people's wellbeing.

What is safeguarding in a care home specifically? It is the same duty applied to people who are, by definition, dependent on others for their daily care. That dependency creates risk: the risk of neglect through understaffing, the risk of financial abuse by someone who handles a resident's money, the risk of harm from another resident, and the risk that abuse goes unseen because the person cannot report it. A care home's safeguarding arrangements exist to see what the resident cannot say.

Care Act 2014 safeguarding: sections 42 to 47

Section 42 places a duty on the local authority to make enquiries, or cause them to be made, where it has reasonable cause to suspect that an adult in its area has needs for care and support, is experiencing or at risk of abuse or neglect, and as a result of those needs is unable to protect themselves. All three parts must apply. The enquiry decides what action is needed and by whom. Section 43 requires every local authority to have a Safeguarding Adults Board. Section 44 sets out Safeguarding Adults Reviews, which the Board must arrange when an adult has died or been seriously harmed and there is concern about how agencies worked together. Section 45 gives the Board a power to require information. Section 46 abolished the old power of local authorities to remove people from their homes. Section 47 covers protecting property while a person is in hospital or a care home.

What this means for a provider is simple. You do not conduct the section 42 enquiry. The local authority does, though it may ask you to carry out an internal investigation as part of it. Your duty is to recognise, respond, record and report, and to cooperate fully. Care Act 2014 safeguarding is a local authority process into which you feed.

The six safeguarding principles

The statutory guidance sets out six care act 2014 safeguarding principles that should shape every decision. Empowerment: people are supported to make their own decisions and give informed consent. Prevention: it is better to act before harm occurs. Proportionality: the least intrusive response appropriate to the risk. Protection: support and representation for those in greatest need. Partnership: local solutions through services working with their communities. Accountability: transparency in delivering safeguarding.

At a glance: the ten types of abuse in the statutory guidance

Every member of staff should be able to name most of these, and every manager should be able to give safeguarding adults examples of each from their own experience. If you cannot, your training is too abstract.

Physical abuse and the signs that matter

Physical abuse in a care home is rarely a punch. It is more often rough handling during personal care, a hoist used without a second person, a resident being pulled up by the arms, or medication given covertly without a best-interests decision. The signs are bruises in places where accidental injury is unlikely, such as the inner arm, the inner thigh, the back or the ears, finger-shaped marks, grip marks on the upper arms, and a pattern of injuries to one resident that is not matched by the incident log. Record every mark on a body map at the time, with a measurement and a date, because that is the evidence most often missing when a case reaches an enquiry. Watch also for a resident who flinches when a particular member of staff approaches or who becomes distressed at personal care time.

Neglect and acts of omission

Neglect is the most common category in care home safeguarding, and it is usually a failure of the system rather than of one person. A resident loses weight over three months and nobody escalates the MUST score. A pressure sore develops because repositioning was recorded but not done. Fluids are charted at 600ml a day for a week and no one acts. A hospital appointment is missed because nobody booked transport. None of these involve a single villain. All of them are neglect.

The defence against neglect is the daily record and someone reading it. Weight charts, fluid charts, repositioning charts and MAR charts exist so that a pattern can be seen before harm is done. A manager who reads the exception reports every morning will catch the fluid chart in the second week. A manager who reads them at the monthly audit will catch it after the urinary tract infection and the hospital admission. If you use digital daily logs, set the alerts so that a missed repositioning or a low fluid total is visible on the day, not at month end.

Psychological and emotional abuse

This is the abuse that leaves no mark and is the hardest to evidence. In a care home it looks like a member of staff who speaks to residents as though they are children, who threatens to leave someone in bed if they do not cooperate, who ignores a resident's call bell as a punishment, or who mocks a person's confusion in front of others. It also looks like a rigid regime that denies choice: no drinks after 8pm, no visitors at mealtimes, no going outside without permission.

The signs are in the resident's behaviour: withdrawal, tearfulness, refusing care from one person, a change in sleep or appetite, or a resident who has become unusually compliant. Staff often notice and do not report because it feels minor or because the colleague is popular. Your safeguarding training and your whistleblowing policy have to make it plain that this is abuse, that it is reportable, and that the person reporting it will be protected. The point of a culture of openness is that psychological abuse gets named early, before it becomes the norm on a unit.

Financial and material abuse

Care homes handle money for residents, and that creates risk. Personal allowance accounts, shopping done by staff, trips paid for from a resident's cash, gifts to staff, and relatives who hold a power of attorney but do not use it for the resident's benefit. The signs are money that does not reconcile, receipts missing, purchases the resident could not have wanted, unpaid fees or bills where a relative controls the finances, and a resident who says someone has taken something and is not believed because they have dementia. The controls are two signatures for every transaction, receipts, a monthly reconciliation by someone who does not handle the cash, and a rule that staff never become involved in wills, loans or property. Suspected misuse by an attorney is a safeguarding referral and can be reported to the Office of the Public Guardian.

Sexual abuse

Sexual abuse in care homes is under-reported because staff find it hard to believe and residents find it hard to tell. It includes any sexual act the person has not consented to or cannot consent to, and that includes sexual activity between residents where one lacks capacity. It also includes staff exposing residents to sexual material, sexualised touching during personal care, and sexualised comments. The signs are physical injury, bleeding, bruising to the thighs or genital area, torn clothing, a sudden change in behaviour, fear of a particular person or place, and new sexualised language or behaviour.

Organisational abuse

Organisational abuse is the category providers least like to think about, because it is about them. It is neglect or poor practice caused by how the service is run: routines built around staff convenience, residents got up at 6am because the night staff want them ready for the day shift, meals served in a rush, call bells unanswered because the staffing level is wrong, a culture in which staff talk over residents and about them. Winterbourne View was organisational abuse. So is a home where nobody is cruel but everyone is too busy to care. The signs are in the pattern rather than the incident: residents all in bed by 7pm, a silent dining room, complaints that keep saying the same thing. Walk the floor at 6am and at 8pm and ask whether you would want your parent there.

Discriminatory abuse, domestic abuse, modern slavery and self-neglect

Discriminatory abuse is unequal treatment because of a protected characteristic. In care homes it shows up as residents from a minority background being left out of activities, a resident's faith or dietary needs being ignored, a gay resident being mocked, or a person with a learning disability being spoken to differently from older residents in a mixed home. Domestic abuse does not stop at the care home door. A controlling partner or child may continue to control the resident's money, visits or decisions, and staff may see distress after visits.

Modern slavery in a care setting is usually about staff: workers whose passports are held by someone else, who are paid below the minimum wage after deductions, or who live in accommodation controlled by the person who recruited them. Sponsorship arrangements have made this more visible. Self-neglect is where the person is harming themselves by refusing care, food or medical attention, and it sits at the edge of safeguarding because it involves capacity and choice. A resident with capacity who refuses to wash is exercising a right. A resident who is refusing because of untreated depression may not be. The answer is a capacity assessment and a multi-agency conversation, not a shrug.

Resident-on-resident incidents

In learning disability, mental health and dementia services, one resident harming another is common. It is still safeguarding. The person harmed is an adult at risk, and the person causing harm may also be an adult at risk who needs support rather than blame. The response is to separate, treat, record, refer, and then look hard at the placement mix and the environment. A resident who repeatedly assaults others may be in the wrong service, and a safeguarding referral is the mechanism by which that conversation with the commissioner starts.

Do not make the mistake of recording these as behaviour incidents only. They go on the incident log with a safeguarding flag, they are reported to the local authority, and if there is an injury or an allegation of abuse they are notified to CQC. For the incident side see incident reporting in care homes.

Raising a safeguarding concern: the internal route

Every member of staff needs to know the internal route without looking it up, and it should be the same on nights as on days. Raising a safeguarding concern is a procedure, and this is the one that has worked in my own homes.

1. Make the person safe. Attend to any injury, call an ambulance if needed, and separate the person from the alleged source of harm. Safety comes before any paperwork.
2. Tell the person in charge immediately. On nights that is the senior on duty, who phones the on-call manager. Do not wait until handover. Do not wait for the manager to be in.
3. Do not investigate. Do not question the resident beyond what is needed to keep them safe. Do not confront the alleged perpetrator. Do not discuss it with colleagues who do not need to know.
4. Preserve evidence. Leave the room as it is if a crime may have been committed. Keep clothing or bedding in a paper bag. Do not wash the person until advised by the police or the safeguarding team unless medical need requires it.
5. Write it down in your own words. What you saw, heard or were told, when, where, and who was present. Use the resident's actual words in quotation marks. Sign, date and time it. Do this before you go off shift.
6. The manager decides and records the decision. The same day, the manager records whether the concern is being referred to the local authority, to the police, and notified to CQC, with reasons. If the decision is not to refer, the reasons are recorded and the concern is still logged.
7. The manager tells the person and their representative what is happening, unless doing so would increase the risk, and records their wishes.

Step 6 is where homes go wrong most often. A manager who is unsure should refer. The local authority would rather screen out a referral than find out later that a home sat on a concern.

Reporting safeguarding issues in care homes: who outside the home

Reporting safeguarding issues in care homes involves up to four organisations, and it is not a choice between them. The local authority adult safeguarding team receives the safeguarding referral for any concern that may meet the section 42 threshold. Most councils have an online form and a phone line, and an out-of-hours emergency duty team. The police are contacted where a crime may have been committed, which includes assault, theft, sexual abuse and wilful neglect or ill-treatment under section 44 of the Mental Capacity Act 2005 or section 20 of the Criminal Justice and Courts Act 2015. CQC is notified under Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 of any allegation of abuse in relation to a person using the service, and of other events such as serious injury or police involvement. The commissioner, whether the local authority placing team, the ICB for CHC-funded residents, or an out-of-area council, is told because they fund the placement and have their own contract requirements.

How to report safeguarding issues is a question that should be answered on one laminated sheet in the office: the local authority number and portal, the out-of-hours number, the police non-emergency and emergency numbers, the CQC notification route, and the commissioner contacts. If the sheet is not there, make it today. For the CQC side see CQC notifications: what to report.

What a good referral contains

A safeguarding referral that helps the local authority act quickly contains the person's details and their care and support needs, what happened or what is suspected in plain factual terms, when and where, who was involved and who witnessed it, what immediate action you have taken to keep the person safe, whether the police have been informed, whether the person has capacity to understand the concern and what their wishes are, whether they know a referral is being made, who else knows, and what you think should happen next. Attach or reference the body map, the incident report and the staff statement.

Identify ways to ensure evidence of abuse is preserved

This phrase appears in the Care Certificate and in most safeguarding training because it is where cases fall apart. Ways to ensure evidence of abuse is preserved include: leaving the scene undisturbed where a crime may have been committed and restricting access to it; not washing the person or changing their clothes until advised, unless there is a medical need; placing clothing and bedding in separate paper bags, not plastic; not touching objects that may carry fingerprints; photographing injuries only where policy and consent allow and with the date and a measurement; completing the body map at the time; writing statements before staff go off duty and before they talk to each other; securing CCTV footage before it is overwritten; and keeping the original records unaltered, with any later additions dated and signed.

Digital care records help here because every entry is timestamped and an amendment leaves the original in place. On paper, the rule is that nothing is ever crossed out so it cannot be read, and nothing is ever written in later without a date. If a member of staff wants to add to a statement the next day, they write a second statement.

Making Safeguarding Personal and the person's wishes

Making Safeguarding Personal is the approach in the statutory guidance that puts the person's outcomes at the centre. In practice it means asking the resident, at the start, what they want to happen, and recording it. Some people want the perpetrator prosecuted. Some want nothing more than for it to stop and for no one to know. Some want to move. The enquiry should aim at the outcomes the person wants, unless there is a wider public interest or others are at risk.

Where the person lacks capacity to make decisions about the safeguarding process, the Mental Capacity Act applies. Decisions are made in their best interests, and an independent advocate is arranged under section 68 of the Care Act where there is no appropriate person to support them. Record the capacity assessment for this specific decision. Do not assume that a diagnosis of dementia or a learning disability means the person cannot express a wish about what should happen to them. Most can, if asked properly. Most can, if asked properly, and the record should show that they were.

The section 42 enquiry and the provider's role

Once a referral is accepted, the local authority decides whether the three-part section 42 test is met and, if so, what enquiry is needed. It may conduct the enquiry itself, ask the police to lead where there is a crime, or ask the provider to carry out an internal investigation and report back. If you are asked to investigate, appoint someone who was not involved, set out the terms of reference, interview staff and the resident, review the records, and produce a factual report with findings and actions. Send it within the timescale asked for and be ready for the local authority to challenge it.

A strategy meeting or discussion often follows, with the home, the local authority, the police, the commissioner and sometimes the family. Your registered manager attends, brings the records, and is honest. The outcome may be a protection plan for the resident, actions for the provider, a referral to the Disclosure and Barring Service for a staff member, or a decision that abuse was not substantiated. Whatever the outcome, record it against the concern in your log and close it with the date.

CQC notifications and the duty of candour

Regulation 18 of the Registration Regulations requires you to notify CQC without delay of any abuse or allegation of abuse in relation to a person using the service. Without delay means the same day or the next working day, not after the enquiry concludes. The notification is separate from the local authority referral. Doing one does not do the other. Regulation 20 of the Regulated Activities Regulations, the duty of candour, applies where a notifiable safety incident has caused or could cause moderate or severe harm: you tell the person or their representative what happened, apologise, offer support, and follow up in writing.

These duties overlap with safeguarding but are not the same. A resident-on-resident assault that causes a fracture triggers a safeguarding referral, a CQC notification for the abuse allegation and for the serious injury, a duty of candour conversation and letter, and a commissioner notification. A good safeguarding log records all four with dates so that an inspector can see the sequence.

Whistleblowing in care homes

Whistleblowing in care homes is safeguarding by another name. Staff who raise concerns about colleagues, about management or about the way the home is run are protected under the Public Interest Disclosure Act 1998, and CQC is a prescribed body to which staff can whistleblow directly. Your policy must say that staff can raise concerns internally, with the local authority, with CQC or with the police, that they will not be victimised, and that anonymous concerns will still be looked at.

More important than the policy is the experience of the last person who raised a concern. If they were thanked, kept informed and saw something change, the next person will speak up. If they were frozen out, nobody will. Managers should say, at every team meeting, that they want to hear concerns, and then prove it. The full picture is at whistleblowing in care homes.

Training, the safeguarding lead and the DBS

Every member of staff completes safeguarding adults training at induction, as part of the Care Certificate, and refreshes it at least annually, with a higher level for seniors and managers. The training must cover the ten types of abuse, the signs, the internal route, the external route, and the person's own role in preventing abuse. It must include scenarios from your own type of service, because the signs of abuse in a learning disability home are not the same as in a nursing home for older people.

Name a safeguarding lead, usually the registered manager, and a deputy, and put their names on the wall. Make sure the on-call arrangements mean that a senior can always reach someone who can make the referral decision. Recruit safely: an enhanced DBS check with the adults' barred list before the person starts, references verified, gaps in employment explained. And refer staff to the DBS where you have dismissed or removed them because they harmed or posed a risk to an adult, which is a legal duty, not an option. A training matrix that flags safeguarding refreshers and DBS renewals before they lapse is the practical control here.

The safeguarding log and what it must show

Every concern, whether or not it was referred, goes on a safeguarding log. The log records the date, the resident, the type of abuse suspected, a short summary, who raised it, the decision on referral with reasons, the date of the referral and the local authority reference, the CQC notification date, the police reference if any, the person's wishes, the actions taken to protect them, the outcome of the enquiry, the lessons learned and the date closed. It is reviewed weekly by the manager and monthly at the governance meeting.

A log kept in a spreadsheet works. A log that sits inside the incident system, so that an incident with a safeguarding flag automatically becomes a log entry with its root cause review attached, works better because nothing is transcribed and nothing is lost. Kiwi handles it that way: an incident is reviewed for root cause, flagged as safeguarding where it meets the threshold, and the referral and notification dates are recorded against it, so the log and the incident file are the same record. Whatever tool you use, the test is whether you can produce, in under five minutes, every safeguarding concern in the last twelve months with its outcome. Then read it for patterns at the monthly governance meeting, by unit, by shift and by staff member, alongside complaints, incidents and weight and skin data, because that is where organisational abuse hides.

Safeguarding checklist for managers

• Safeguarding policy that names the local authority procedures, the internal route and the external contacts, reviewed annually
• Named safeguarding lead and deputy, with on-call cover that can make referral decisions at any hour
• Contact sheet for the local authority, out-of-hours team, police, CQC and commissioners in the office and the night office
• All staff trained at induction and refreshed annually, seniors and managers at a higher level, with scenarios from your own service type
• Body maps, incident forms and statement forms available on every unit and used at the time
• Safeguarding log covering every concern, referred or not, with decisions, references and outcomes
• CQC notification made for every allegation of abuse, same day or next working day
• Duty of candour conversation and letter where the harm threshold is met
• Financial procedures for residents' money with two signatures and monthly reconciliation
• Whistleblowing policy that staff have read, with evidence that concerns raised were acted on
• DBS checks before starting and referrals to the DBS where the legal duty applies
• Monthly governance review of the log alongside complaints, incidents and clinical indicators

Common mistakes

• Waiting for proof before referring, when the threshold is reasonable cause to suspect
• Investigating internally first and referring only if something is found
• Treating resident-on-resident harm as a behaviour incident rather than safeguarding
• Referring to the local authority but forgetting the CQC notification, or the other way round
• Body maps completed the next day from memory, or not at all
• Not asking the person what they want to happen, or not recording it
• Staff statements written after the team has discussed the incident together
• A safeguarding log that only contains referred concerns, so the pattern of near-misses is invisible

What good looks like on inspection day

An inspector will ask for the safeguarding log and pick two or three concerns to track. For each one they want to see the original incident record and body map, the staff statement in the staff member's own words, the manager's decision recorded the same day, the referral to the local authority with its reference, the CQC notification with its date, the person's wishes, the protective actions, the outcome and the lessons learned. They will check the dates against each other to see whether you acted without delay. They will check the CQC notification against their own records.

Then they will ask care staff, including agency staff, what they would do if they suspected abuse and who they would tell. They will ask residents and relatives whether they feel safe and whether they know how to raise a concern. They will look at the way the home runs at the busiest and quietest times for signs of organisational abuse. Inspection-ready evidence is a log that reconciles with the notifications, statements that read as though a real person wrote them at the time, and a team that gives the same answer as the policy. If you want to see how an incident with a safeguarding flag carries its referral, notification and root cause in one place, book a demo.

Final conclusion

Safeguarding adults in care homes is not a separate activity from care. It is what happens when good care is paid attention to. Know the ten types of abuse and the signs they leave in your own kind of service. Train staff to make the person safe, tell the senior, preserve evidence and write it down. Refer to the local authority when there is reasonable cause to suspect, notify CQC of every allegation, involve the police where a crime may have happened, and ask the person what they want. Keep a log of everything, read it for patterns, and act on what it shows. Do that consistently, and the residents who cannot speak for themselves have a home that speaks for them.

Frequently asked

Do I need proof before making a safeguarding referral?

No. The section 42 threshold is reasonable cause to suspect that an adult with care and support needs is experiencing or at risk of abuse or neglect and cannot protect themselves. The local authority decides whether to make enquiries, so refer when you are unsure and let them screen it.

Does every safeguarding concern have to be reported to CQC?

Every allegation of abuse in relation to a person using the service must be notified to CQC under Regulation 18 of the Registration Regulations, without delay. A concern that is clearly not abuse, such as a resident who has capacity choosing to refuse a bath, does not need a notification but should still be logged. When in doubt, notify.

What is organisational abuse in a care home?

It is neglect or poor practice caused by the way the service is run rather than by one person's actions. Rigid routines, understaffing, rushed meals, unanswered call bells and a culture where staff talk over residents are all examples. Managers find it by walking the floor at different times of day and reading complaints and incidents for patterns.

What are the six safeguarding principles in the Care Act 2014?

Empowerment, prevention, proportionality, protection, partnership and accountability. They come from the statutory guidance and describe how every concern should be handled: ask the person what they want, act early, respond in proportion to the risk, protect those most in need, work with other agencies, and record what you did and why.

How do I raise a safeguarding concern as a care worker?

Make the person safe, tell the senior or manager on duty straight away, do not investigate or confront anyone, preserve any evidence, and write down what you saw or heard in your own words before you go off shift. If you believe your manager is not acting, you can contact the local authority safeguarding team or CQC directly and you are protected in law for doing so.

Is an incident between two residents a safeguarding matter?

Yes, if one resident has been harmed or is at risk of harm from another. The person harmed is an adult at risk, and the person causing harm may also need support. Separate them, treat any injury, record it, refer to the local authority, and notify CQC if there is an injury or an allegation of abuse.

Should a care home investigate a safeguarding concern before referring it?

No. Refer first and investigate only if the local authority asks you to as part of its section 42 enquiry. Investigating first delays protection, risks contaminating evidence and can look like an attempt to manage the concern internally. If asked to investigate, use someone who was not involved and report back within the agreed timescale.

Sources

• Care Act 2014, sections 42 to 47
• GOV.UK: Care and support statutory guidance (Care Act 2014), chapter 14: Safeguarding
• Care Quality Commission (Registration) Regulations 2009, Regulation 18: Notification of other incidents
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 13: Safeguarding service users from abuse and improper treatment
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20: Duty of candour
• Mental Capacity Act 2005
• Public Interest Disclosure Act 1998
• Local Government Association and ADASS: Making Safeguarding Personal