Level 3 safeguarding training and standards

Induction

All new Level 3 staff members should, within their induction period:

• have a practice/organisational safeguarding induction AND
• complete relevant safeguarding Level 3 e-learning modules such as the RCGP e-learning modules on core safeguarding in general practice (or provide evidence of prior completion)
• meet with the practice/organisational safeguarding lead, their deputy or other relevant senior leader within one month of starting their new role to:
  • discuss the safeguarding structure, policies and procedures within the practice/organisation
  • identify any areas of professional development need related to safeguarding

Annually: Level 3 safeguarding update

Level 3 safeguarding updates should be aligned to the RCGP safeguarding standards for general practice and could include:

• topics across the breadth of the five key areas of the safeguarding standards
• child and adult safeguarding, including topics which apply to both e.g. transitional safeguarding, domestic abuse
• practical applications to general practice such as the use of case-based learning
• relevant learning from any local or national safeguarding reviews
• multi-agency and multi-disciplinary safeguarding learning
• relevant safeguarding updates
• role-specific safeguarding training and updates

Updates could be face-to-face or virtual. It could include watching a recorded update.

Annually: Engage in safeguarding learning and reflection

Safeguarding learning and reflection should, over time (for example over a revalidation cycle), be across the breadth of the five areas of knowledge and capabilities in the RCGP safeguarding standards.

• This could be demonstrated through the use of the RCGP Safeguarding Reflective Practice - Structured Template and the RCGP Safeguarding Case Review - Structured Template. These completed templates could also support appraisal and revalidation.
• Practitioners should cover both children and adult safeguarding in their learning and reflection, including practitioners who only work with adults.

Learning and reflection across the five areas of safeguarding knowledge and capabilities could include:

• Safeguarding case discussion. The Safeguarding Case Review - Structured Template could be used to demonstrate case reflection (individual reflection or case-based discussion)
• Regular attendance at practice/organisational safeguarding meetings with reflection on learning and impact on practice
• Example of documenting safeguarding concerns and information and how risks were dealt with
• Example of information sharing or involvement in multi-agency working with reflection on good practice and/or areas for development
• Reading and/or online learning with reflection on impact on practice
• Attendance on a safeguarding update/course with reflection on learning
• Safeguarding CPD activities with reflection on learning and impact on practice
• Safeguarding quality improvement activities
• Safeguarding significant events with reflection on learning and impact on practice
• Participation in statutory reviews and quality improvement activities or learning and impact on practice that may have resulted from this
• Multi-agency safeguarding training or learning events with reflection on learning and impact on practice

1. Professional safeguarding responsibilities

Knowledge

• Understand your statutory, legal and professional safeguarding responsibilities as set out by the relevant professional regulatory body (e.g. GMC, NMC), in relevant legislation and national safeguarding guidance in the UK nation you work in
• Understand and follow professional safeguarding responsibilities as set out in terms of employment
• Awareness of the impact of safeguarding issues on own wellbeing and how to access support as necessary
• Awareness of how and when to raise any concerns about behaviour or actions of colleagues or anyone in a position of trust that have caused harm, or may cause harm to patients or others
• Awareness of practice/organisational policies on managing allegations against staff and whistle blowing policies
• Awareness of local safeguarding professional contact details and referral processes

Capabilities

• Be able to carry out your statutory, legal and professional safeguarding responsibilities as set out by the relevant regulatory body (e.g. GMC, NMC), relevant legislation and national safeguarding guidance in the UK nation you work in
• Be able to carry out professional safeguarding responsibilities as set out in terms of employment
• Ensure that professional competence in safeguarding is maintained and keep up to date with changes in safeguarding
• Be able to recognise how own beliefs, experience and attitudes might influence professional involvement in safeguarding work
• Be able to recognise how own actions impact on others
• Be able to promptly act on any concern about behaviour or actions of colleagues or anyone in a position of trust that have caused harm, or may cause harm to patients or others, including how to report and escalate concerns outside your organisation should this be necessary
• Be able to locate local safeguarding professional contact details and referral processes

2. Identification of abuse and neglect

Child abuse and neglect

Knowledge

• Knowledge of indicators and signs of all types of child abuse and neglect including (but not limited to): Neglect, physical abuse, sexual abuse including contact and non-contact abuse, emotional abuse, child sexual exploitation (CSE), Child Criminal exploitation (CCE), County Lines, FGM (including specific legal requirements for reporting), domestic abuse, fabricated and induced illness and perplexing presentations, radicalisation (including how and when to refer to the Prevent programme for practitioners in England, Wales and Scotland)
• Knowledge of Adverse Childhood Experiences (ACEs) and their lifelong impact
• Knowledge of contextual safeguarding i.e., extra-familial risks such as school, college, wider community, peers, online
• Knowledge of how abuse and neglect may present at different ages and the prevalence of different types of abuse in different age groups
• Knowledge of the impact on child wellbeing of parental issues e.g., parental behaviour, mental health and substance misuse
• Knowledge of safeguarding and welfare issues that can arise in the perinatal period
• Knowledge of safeguarding issues specific to children under one-year-old e.g., abusive head trauma
• Knowledge of the increased needs and vulnerabilities of children on child protection plans, Looked After Children, children with disabilities, unaccompanied asylum seeking children, care leavers, young carers and missing children and that these needs may continue into adulthood
• Awareness that children not in education or training (NEETs) or those who are home schooled may not be visible to the usual range of services
• Awareness of issues specific to young people aged 16 and 17 years old including capacity legislation and the risks of 'falling through the gaps' between child and adult services
• Understand which children may be at greater risk of abuse and neglect
• Understand the rights of the child as defined in national and international law (see the RCGP safeguarding toolkit, part 2, for further information)
• Awareness of the findings, recommendations and learning from the Independent Inquiry into Child Sexual Abuse (IICSA) (see the RCGP safeguarding toolkit, part 2, for further information)

Capabilities

• Be able to give safe sleeping advice and the ICON advice to parents of babies
• Be able to identify Adverse Childhood Experiences (ACEs) and take action to minimise their impact
• When treating adults, be able to take appropriate action to safeguard any children who may be at risk of harm due to the adult’s health or behaviour
• Be able to apply the principles of consent and confidentiality in relation to young people under the age of 18 including the concepts of Gillick Competency and Fraser Guidelines
• Be able to assess mental capacity and apply the principles of mental capacity legislation for those aged 16 years and over
• Be able to take a proactive role in exploring any indicators of abuse and neglect and take preventative action to ensure adequate support and protection
• Be able to uphold the rights of the child as defined in national and international law
• Be able to implement learning from the Independent Inquiry into Child Sexual Abuse and The Truth Project
• Be able to identify, and take appropriate action on, safeguarding indicators related to medication and prescribing e.g. inappropriate medication requests for children, medication not being requested or picked up for a prolonged period of time
• Be able to identify risk to children, especially infants, when parents/carers are taking addictive or sedative prescribed medication
• Be able to provide support as needed to remove barriers to healthcare such as facilitating choice of mode of consultation

Adult abuse

Knowledge

• Knowledge of indicators and signs of all types of adult abuse including (but not limited to): physical abuse, sexual abuse, psychological abuse, financial abuse, emotional abuse, domestic abuse, organisational abuse, modern slavery/trafficking, discriminatory abuse, organisational or institutional abuse, neglect or acts of omission, self-neglect, radicalisation (including how and when to refer to the Prevent programme for practitioners in England, Wales and Scotland)
• Awareness that adults who have experienced abuse in childhood may have specific vulnerabilities and risks in adulthood resulting from adverse childhood experiences (ACEs)
• Awareness of the importance of adult rights in the safeguarding context, and the essential knowledge of relevant legislation e.g. mental capacity legislation
• Awareness of what constitutes an ‘adult at risk’
• Knowledge the importance of the adult being as fully involved as possible in adult safeguarding processes, e.g. Making Safeguarding Personal (MSP) - SCIE
• Understand the significance of health deficits on health and wellbeing through the life course, e.g. homelessness, loneliness and poverty
• Awareness of the importance of effective advocacy for the adult at risk of abuse, harm or neglect
• Understand the effects of carer behaviour and family factors on adults at risk of abuse, harm or neglect
• Awareness of deprivation of liberty legislation (e.g. Deprivation of Liberty Safeguards, Liberty Protection Safeguards) as applies in the UK nation you work in (Mental capacity - ethical topic - GMC)
• Understand which adults may be at greater risk of abuse and neglect

Capabilities

• Be able to demonstrate the practical applications of the key principles of adult safeguarding as outlined in legislation and guidance in each UK nation
• Be able to demonstrate the inclusion and participation of the adult as much as possible in safeguarding processes
• Understand the effects of carer behaviour and family factors on adults at risk of abuse, harm or neglect and the inter-agency response
• Be able to support adults at risk who do not feel able to participate in service support, for example those experiencing coercive control and those who face multiple barriers to services
• Be able to take a proactive role in exploring any indicators of abuse and neglect and take preventative action to ensure adequate support and protection
• Be able to identify, and take appropriate action on, safeguarding indicators related to medication and prescribing e.g. inappropriate medication requests for adults with care and support needs, medication not being requested or picked up for a prolonged period of time
• Be able to provide support as needed to remove barriers to healthcare such as facilitating choice of mode of consultation

Mental capacity

Knowledge

• Knowledge and understanding of mental capacity legislation as relevant to the country of practice
• Knowledge and awareness of indicators that should prompt assessment of mental capacity
• Knowledge and understanding of the factors that can impact on, and cause, fluctuating mental capacity
• Knowledge and understanding of the two elements involved in mental capacity: decisional capacity and executive capacity
• Knowledge and understanding of the factors which can impact executive capacity
• Awareness of situations where assessment of mental capacity may be more challenging and complex. For example: learning disabilities, self-neglect, fluctuating capacity, alcohol/drug addiction, Multiple Exclusion Homelessness, history of trauma, where there are concerns about coercion such as in the context of domestic abuse, modern slavery and trafficking or criminal/sexual exploitation. Understand that in these situations mental capacity assessments may need to be carried out over a period of time and by more than one professional
• Knowledge and awareness of deprivation of liberty legislation (e.g. Deprivation of Liberty Safeguards, Liberty Protection Safeguards) as applies in the UK nation you work in (GMC Ethical hub: Mental capacity)
• Understand who needs to be included or consulted with when making decisions in a person’s best interests
• Knowledge and awareness of the roles of advocates (e.g. IMCAs – Independent Mental Capacity Advocates) and lasting power of attorney
• Understand the role of the Court of Protection
• Understand the decision and time specific nature of mental capacity and hence the need to reassess capacity appropriately
• Understand the advantages, challenges, and ethics of advance care planning, and how to discuss these with the person and their carers, family and friends.

Capabilities

• Be able to assess mental capacity and apply the principles of mental capacity legislation, including in situations where capacity fluctuates or is complex. For example, where there are learning disabilities or where there are concerns about self-neglect, fluctuating capacity, alcohol/drug addiction, Multiple Exclusion Homelessness, history of trauma, and concerns about coercion such as in the context of domestic abuse, modern slavery and trafficking or criminal/sexual exploitation
• Be able to make, and contribute to, best interest decisions for people without capacity, within the framework of relevant legislation
• Recognise when there are factors potentially impacting on executive capacity and take these into account when assessing mental capacity
• Recognise when a mental capacity assessment needs to be carried out or repeated
• Be able to clearly document mental capacity assessments and best interest decisions, including the decision-making process, in the patient record
• Be able to seek advice and guidance from more experienced colleagues/safeguarding lead/safeguarding professionals, when necessary
• Be able to communicate effectively with adults, to recognise and to ensure those lacking capacity to make a particular decision, or with communication needs, have the opportunity to participate in decisions affecting them
• Be able to support individuals to make complex decisions within the framework set out by mental capacity legislation
• Be able to seek specialist communication support where necessary
• Be able to support people to plan for when they may lack capacity in the future
• Be able to determine whether an advance decision is valid and applicable
• Be able to determine how and when to have potentially difficult conversations about loss of autonomy, advance care planning or death
• Be able to recognise restrictions being placed on an individual and assess whether these are proportionate to the person’s needs and risks of harm
• Be able to identify when an individual is being deprived of their liberty and make appropriate referrals
• Be able to contribute to community deprivation of liberty assessments when necessary.

Domestic abuse

Knowledge

• Knowledge and understanding of what domestic abuse is and the wide range of different types of abuse that can be seen within a domestic abuse context e.g. 'honour' – based abuse; physical, emotional, psychological, sexual, financial, economic abuse; coercive control; stalking; non-fatal strangulation
• Knowledge and understanding that victims and perpetrators can be any age, gender, sexuality, race and come from any background
• Knowledge of how victims (child and adult) of domestic abuse might present in general practice, including common presenting physical and mental health issues, additional barriers to support and circumstances which can increase risk, such as pregnancy or leaving an abusive relationship
• Understand the impact of domestic abuse on health and wellbeing, which can be lifelong, including that it can sometimes be fatal
• Knowledge that the Domestic Abuse Act 2021 considers children who see, hear or experience domestic abuse as victims of domestic abuse as opposed to witnesses (external PDF)
• Understand that domestic abuse will not necessarily always require a safeguarding referral
• Knowledge of local and national domestic abuse organisations, how they support victims and how to refer/signpost to them

Capabilities

• Be able to recognise signs and indicators of domestic abuse which should prompt professional curiosity
• Be able to recognise and respond appropriately to the different levels of risk in domestic abuse which can include: referral/signposting to domestic abuse agencies, safeguarding considerations (child and adult) and making MARAC referrals when there are signs of high risk domestic abuse
• Be able to document information about domestic abuse accurately and safely in the patient record, taking into consideration the risks associated with patient online access
• Be able to share information appropriately to MARAC, and other agencies, when appropriate and necessary
• Be able to respond appropriately to perpetrators of domestic abuse including addressing any health needs

Organisational or institutional abuse or neglect

Knowledge

• Awareness of potential signs of abuse and neglect in an organisation/institution (e.g. care/nursing homes, homes for adults with learning disabilities)
• Understand the importance of escalating concerns, however minor, about an organisation to the relevant professionals/agencies

Capabilities

• Be able to identify early warning signs as well as potential signs of abuse and neglect in an organisation/institution that could indicate organisational abuse/neglect and raise these concerns in line with local safeguarding procedures

Supporting victims and survivors of abuse

Knowledge

• Understand the potential lifelong impact of abuse (including ACEs - Adverse Childhood Experiences) on multiple aspects of a person's life including physical and mental health, education, jobs, forming relationships, parenting, drug and alcohol issues, criminal behaviour
• Understand that trauma exposure can impact an individual's neurological, biological, psychological and social development

Capabilities

• Be able to approach health and care interventions grounded in the understanding of the impact of trauma exposure
• Be able to learn from those with lived experience of abuse including own patients
• Be able to learn from significant safeguarding events within own practice/patient population
• Be able to learn from local and national safeguarding reviews
• Be able to reflect on these lived experiences and significant/safeguarding reviews/events, and apply lessons to own professional practice

Working with perpetrators of abuse

Knowledge

• Awareness that general practice provides services for everyone which will include those perpetrate abuse
• Understand that those who perpetrate abuse towards others may have significant health needs
• Understand that children and young people who cause harm to others will also need to be safeguarded appropriately. This may also apply to adults with care and support needs
• Understand actions that may need to take place within the practice to manage high risk persons such as those highlighted to the practice from MAPPA (Multi-agency Public Protection Arrangements) or PPANI (Public Protection Arrangements Northern Ireland) if there are agreed local processes in place with general practice for this to occur

Capabilities

• Be able to work with, and care for, those who perpetrate abuse towards others without minimising, dismissing or condoning the harm caused
• Where a victim of abuse and their perpetrator are at the same practice, care is taken to ensure services are provided safely to both

3. Responding to abuse and neglect

Knowledge

• Understand that identifying abuse can involve building up a picture over time and can necessitate liaison with other professionals
• Awareness of the potential implications to children and young people, as well as adults with care and support needs, of not being brought to health appointments
• Recognise obligations to act when there is a safeguarding concern and acting is against the expressed wishes of the person/family/carers
• Understand when a child or adult safeguarding referral is needed
• Awareness of local referral processes for child and adult safeguarding including early help services
• Knowledge of whom to speak to for further advice if unsure how to respond e.g. Practice Safeguarding Lead, Named GP for safeguarding, local safeguarding team, Designated Professionals for safeguarding
• Knowledge of how to escalate concerns about abuse when there is an insufficient or inadequate response from within the organisation or from other agencies
• Knowledge of how to promptly manage and report any concerning behaviour or allegations of abuse by a person in a position of trust, including colleagues

Capabilities

• Ensures the voice and the lived experience of the child, or adult with care and support needs, is paramount
• Willingness to listen to children, young people, adults at risk, families and carers and to act on issues and concerns
• Be able to facilitate communication with use of formal interpreters and aids as needed
• Be able to identify when abuse might be occurring, understanding that all types of abuse can have similar signs and that being able to identify any signs of abuse, however subtle, is important in being able to build up a picture of possible abuse
• Be able to identify possible signs of abuse/neglect in different settings including, but not limited to:
  • Healthcare setting
  • Institutions e.g. care homes, nursing homes, residential homes for people with learning disabilities
  • Patient's homes
• Be able to identify patterns of patients not being brought to general practice health appointments and take appropriate action where relevant to explore whether this could be an indicator of abuse/neglect or an indication that families/carers need more support. (With regard to secondary care or other healthcare provider appointments not brought to, each locality should have robust processes in place involving secondary care, general practice, and other healthcare teams as appropriate such as 0 -19 teams and midwifery teams to ensure patterns of missed appointments are identified, and relevant action is taken by all healthcare providers)
• Be able to ask children, young people and adults about abuse, taking into consideration their age and communication needs
• Be able to ask parents/family members/carers about abuse
• Be able to effectively, sensitively and appropriately communicate professional concerns about abuse to adults, parents/caregivers/family/carers and children and young people (dependent on age)
• Be able to seek appropriate advice and report any safeguarding concerns in line with practice/organisation policy and be confident that they have been understood
• Be able to make effective and appropriate safeguarding referrals when abuse is suspected
• When abuse is being considered, be able to take appropriate action as needed e.g. gather further information, liaison with other professionals and agencies, make appropriate referrals, monitor the situation, use of time to build a picture
• Be able to learn lessons, relevant to role, from significant safeguarding events within own practice/patient population, local and national safeguarding reviews

4. Documenting safeguarding concerns and information

Knowledge

• Awareness of the importance of safely and accurately documenting safeguarding concerns and documentation in the patient record, including other patients’ records as applicable
• Awareness of the safeguarding challenges and risks related to patient online access (if applicable) and how to mitigate these as much as is possible in a general practice setting
• Understand when and what information needs to be redacted in situations such as medical reports and Subject Access Requests, according to data protection legislation

Capabilities

• Be able to document safeguarding concerns safely and accurately in the patient record, including other patients’ records as applicable
• Be able to mark information not for online access (if applicable)
• Be able to accurately and safely document disclosures of abuse in the patient record
• Be able to use appropriate coding to highlight safeguarding concerns in the patient record
• Be able to safely and promptly manage requests from other health professionals or external agencies, for information in a safeguarding context
• Be able to discuss with patients the safeguarding risks of online access (if applicable
• Be able to recognise the safeguarding challenges of patient online access (if applicable) including coercion to access records and have strategies to avoid giving access while seeking help if coercion is suspected, and to support others to do the same
• Be able to redact information as necessary e.g. for medical reports, Subject Access Requests as per data protection legislation, including advising others as necessary

5. Information sharing and multiagency working

Knowledge

• Understand that multi-agency working and information sharing are essential for effective safeguarding
• Understand that general practice holds relevant and important information which is significant for the multi-agency safeguarding response to concerns about abuse and neglect
• Understand that timely, relevant, proportionate and necessary information sharing is fundamental to safeguarding
• Knowledge and understanding of the different applications of consent in the common law and data protection legislation and how both need to be considered separately, but equally, when sharing information for the purposes of safeguarding
• Understand that the common law and data protection legislation (UK GDPR) are not barriers to information sharing – rather they provide a framework to share confidential information safely and appropriately
• Understand terminologies used in multiagency settings such as safeguarding conferences, strategy meetings, MARAC, MARAM, MAPPA, PPANI and statutory reviews in order to be able to prioritise information sharing

Capabilities

• Be able to share relevant and proportionate information for the purposes of prevention of abuse as well as to aid the identification of, and response to, abuse
• Be able to confidently share information appropriately within the practice, with multi-disciplinary teams and multi-agency safeguarding partners, for the purposes of safeguarding
• Be able to apply the common law and data protection legislation to information sharing processes for the purposes of safeguarding
• Be able to confidently have conversations with patients, and their family/carers as appropriate, about information sharing, consent and confidentiality including its limits
• Be able to seek advice if there is any uncertainty about information sharing
• Be able to provide timely safeguarding reports including necessary, proportionate and relevant information e.g. child protection reports, adult safeguarding reports, strategy meetings, MARAC reports (Multi-agency Risk Assessment Conferences)
• Be able to contribute to multi-agency safeguarding processes and discussions such as child protection and adult safeguarding conferences
• Be able to contribute as needed to safeguarding reviews such as domestic homicide reviews, child death reviews, serious case reviews, Coroner’s requests (names of reviews may vary from one UK nation to another)
• Be able to work effectively with other health professionals and other agencies to safeguard children and adults
• Be able to respectfully and professionally challenge colleagues and other professionals when necessary, as well as accepting, and responding to, professional challenge from others