Disclosure, recording, reporting, and preserving evidence

When an adult discloses abuse, or when staff witness a concerning incident, the accuracy of the record is important. Write what happened as soon as you can, including date, time, place, who was present, what you saw, what the adult said, and any action you took. If you record the adult's words, use their exact phrasing where possible.

Keep entries factual. Do not guess, fill gaps with assumptions, or add personal opinions that could affect a later enquiry. If an injury or physical sign is relevant, follow local policy on body maps, photography, medical review, and incident reporting. Preserving evidence is especially important in possible crimes or sexual assaults.

Preserving evidence may mean leaving clothing, bedding, continence products, or the environment undisturbed where it is safe to do so, avoiding unnecessary cleaning, and ensuring electronic records, call bell logs, medication records, or CCTV are not altered or lost. Follow local safeguarding and police guidance.

Share information promptly and only as needed. Internal reporting to the senior on duty or safeguarding lead is usually the first step. If the concern involves the manager or there is a risk it will be suppressed, use alternative internal routes, contact the local authority, use whistleblowing channels, or notify CQC as appropriate.

Good recording practice

• Record promptly, clearly and factually.
• Use the adult's own words where possible.
• Note who you told and when.
• Preserve records, belongings and potential evidence in line with local procedure.

If the concern may involve the manager or the whole service

Good safeguarding records are prompt, factual and careful. They protect the adult and preserve the best chance of a proper enquiry.