Procedure for managing allegations against people in positions of trust (PIPOT)

1 Introduction

This procedure provides the framework for managing cases where allegations have been made against a person in a position of trust (PiPoT) and is focussed on the management of risk. It provides guidance to ensure appropriate actions are taken to manage allegations against people who are employed, or volunteer for the trust.

This procedure is based on the Care Act 2014 which requires that partner agencies and commissioners of services should have clear recording and information sharing guidance set explicit timescales for action and are aware of the need to preserve evidence.

This procedure builds upon the existing statutory provision and local safeguarding adults board procedures.

The trust recognises its responsibility to ensure safe working systems are in place for staff working with children and adults. Having a clear process in place to manage allegations against persons in positions of trust forms one part of this process but needs to sit alongside safe recruitment and selection policies, robust disclosure procedures and training for staff to ensure they understand their responsibilities in terms of safeguarding.

As such, this guidance should be read in conjunction with the following RDaSH policies:

This is not an exhaustive list and reference to additional policies will be considered on a case-by-case basis.

All of the above are available for reference on the intranet under policies. Additional information, for example the South Yorkshire safeguarding procedures, North Lincolnshire policy and procedure, and regional guidelines for PiPoT, are also available on the intranet under clinical information, safeguarding

2 Purpose

Set out clear reporting requirements and the arrangements for the management of allegations against persons in positions of trust, with concise recording, information sharing arrangements and explicit timescales for action.
Ensure that allegations are dealt with expeditiously and in a fair, proportionate and transparent way, adopting the just culture principles.
Ensure that appropriate systems are in place to support and provide regular updates to the employee concerned in respect of any investigation.
Ensure that the control of information in respect of individual cases is in accordance with data protection and confidentiality requirements in line with the general data protection regulation (GDPR).
Ensure that where staff, students and volunteers are found to have had allegations substantiated against them, appropriate governance procedures are followed, including a referral to the individual’s professional body (for example, the nursing and midwifery council [NMC]), the disclosure and barring service (DBS) and the police, where appropriate.

This guidance must be applied when concerns are raised about a person in a position of trust in a work (professional) context and also if any relevant concerns arise from a person’s personal life, if there are implications for the safety of people with care and support needs. This guidance applies whether the allegation or concern is current or historical.

When considering a referral relating to a person in a position of trust, a distinction should be made between an allegation, a concern about a person’s quality of care or practice and a complaint.

Where there are potential risks to adults with care and support needs who use the trust’s services, these risks need to be assessed, and if necessary, action should be taken to safeguard those adults.

Examples of concerns that can arise either in a professional or personal context:

person has behaved in a way that has harmed or may have harmed an adult or child
person has committed a criminal offence against, or related to, an adult or child
person has behaved towards an adult or child in a way that indicates they may pose a risk of harm to adults with care and support needs
person may be subject to an investigation by police as a perpetrator of domestic harm
a person has behaved (or is alleged to have behaved) towards children in a way that indicates that they may pose a risk of harm to adults with care and support needs
a person is subject of a formal safeguarding enquiry into allegations of abuse or neglect which have occurred in one setting. However, there are also concerns that the person is employed, volunteers or is a student in another setting where there are adults with care and support needs who may also be at risk of harm

3 Scope

As a relevant partner to a number of local authorities and an organisation providing care and support services to adults; the trust is required to have a clear process in place for dealing with allegations against ‘persons in positions of trust’.

This guidance sets out the trust’s process when allegations are made against a PiPoT at the trust.

The Care Act 2014 defines people in positions of trust as: ‘people who work, in either a paid or unpaid capacity with adults with care and support needs’. Therefore, although this guidance uses the words ‘employee’ ‘employees’ and ‘staff’ this guidance applies to all staff, volunteers and students working at the trust, who have contact with adults with care and support needs.

3.1 What is excluded from the procedure?

Section 14 of Care Act and support statutory guidance states safeguarding is not a substitute for:

the providers responsibility to provide safe and high-quality care and support
the commissioners regularly assuring themselves of the safety and effectiveness of commissioned services
the Care Quality Commission to ensure providers comply with the standards of care or by taking enforcement action
the core duties of the police to prevent and detect crime, and protect life and property

Therefore, careful consideration should be given to distinguish clearly between:

a complaint about a professional or volunteer
concerns raised about the quality of practice provided by a person in a position of trust that do not meet the criteria for a safeguarding enquiry

Other relevant bodies and their procedures should be used to recognise, respond to and resolve these issues.

4 Responsibilities, accountabilities and duties

Safeguarding adults and children is everybody’s responsibility whatever role you may have within work or outside of work.

4.1 How might A PiPoT concern be identified?

Concerns about a PiPoT’s behaviour may be identified by the following people or procedures:

police intervention
providers alerting commissioners investigation of services
whistleblowing disclosure
commissioner’s contract
safeguarding adults enquiry monitoring activity
safeguarding children
SAB partner investigation
CQC
complaints
any other source of reports from members of the public

4.2 Employee

4.2.1 When an employee of the trust raises a concern

Employees are responsible for conducting themselves in a professional manner at all times to patients, relatives, colleagues, and any other individuals they may come into contact with during the course of their work for the trust.

Any member of staff with knowledge or information that an individual is involved in the actual or potential abuse of an adult or a child, whether in the course of their work, or leisure and personal time, or their family and carer responsibilities, must report it to their line manager (or on call manager) and the Safeguarding team.

Some employees may feel uncomfortable doing this, however, the needs of the adult or child should be paramount. For professional staff this duty will also fall under their professional code of conduct. It should be noted that failure to report concerns could indicate collusion; along with malicious allegations, this would be viewed seriously by the trust and the police may need to be informed.

Employees disclosing information should be listened to and advised that their concern will need to be taken further, where appropriate. Employees should be aware that it may not be possible for their anonymity to be maintained.

4.3 Line managers

4.3.1 Line managers of employees raising concerns

Are responsible for:

ensuring that any concern raised with them is listened to and taken seriously
informing employees that it may not be possible for their anonymity to be maintained
documenting the concern
referring to the trust’s Safeguarding team as soon as possible

Line managers will be responsible for populating the PIPOT referral form and gathering all information, prior to the scoping meeting which may have a bearing on the allegation for example, any previous concerns. This information is to readily accessible during the meeting.

4.3.2 Line manager of an individual who is the subject of a concern or allegation

The manager will attend any meetings as appropriate.
The manager will liaise with the nurse consultant, the Safeguarding team and HR.
The manager will be responsible for notifying and supporting the individual.

4.4 Safeguarding team

On receiving concerns, the Safeguarding team will:

ensure that the incident is measured against the PiPoT decision making tool and that the appropriate person is designated to complete the PiPoT referral form. The safeguarding administrator will record the data in a secure folder
then liaise with the care group or corporate director, line manager and HR and instigate a PiPoT scoping meeting as soon as practically possible
if the concern is raised out of hours, then advice is to be sought from the manager on call and action taken accordingly
if the concern involves children, then the child local authority designated officer (LADO) should be informed immediately
f the adult or child who is the subject of the concern is believed to be at risk of immediate harm, then steps should be taken to safeguard the individual concerned and the police should be informed without delay

4.5 PiPoT lead (Deputy director of nursing, delegated to the nurse consultant for safeguarding)

The PiPoT lead will have the overarching responsibility for the management of the investigation into the allegation(s) and will delegate responsibility for actions to be undertaken.
The responsibilities include:

ensuring staff and managers have access to expert advice and guidance to enable them to fulfil their responsibilities when responding to allegations, which may include legal and human resources guidance
escalating to the director of nursing and allied health professionals
responding promptly to allegations regarding staff and for undertaking necessary action in line with internal processes and agreed timescales
the communication strategy if the allegation(s) is in the public domain
reviewing the information gathered to assess if the allegations are substantiated or not
ensure that the appropriate person is identified to inform the police as appropriate
deciding whether a safeguarding concern should be raised and forwarded to the Local Authority Safeguarding team in accordance with section 42 (Care Act 2014) adult safeguarding enquiry
arranging a scoping meeting with key personnel as detailed in section 5.3 to identify which process, if any, should be followed
monitoring the progress of cases to ensure they are dealt with as quickly as possible, with a consistent, thorough, fair and transparent process
ensuring appropriate recording systems are in place to provide a clear audit trail about the decision-making process and any recommendations arising from an investigation and subsequent actions
assess if this is a serious incident and report as per the trust incident management policy

The PiPoT Lead will ensure that records are maintained regarding the number and nature of allegations made.

5 Procedure and implementation

5.1 Information sharing and confidentiality

Information sharing should comply with the trust’s legal obligations, including under the GDPR and Data Protection Act 2018 (principally that sharing should be fair and lawful, but the legislation should not be a barrier to sharing information where a failure to do so would cause the safety or well-being of a child or adult to be at risk).

To maintain the confidentiality of all parties, no matters related to the PiPoT should be discussed outside of the process.

5.2 Record keeping

A referral form must be fully completed, and any relevant information gathered before a case can be a presented at a PiPoT scoping meeting.
The referrer must also complete an IR1.
All records will be kept in accordance with the trust’s record keeping policies.

All documentation relating to the PiPoT will be kept in a confidential file on the L: Drive

5.3 Process

If a person in a position of trust is alleged to have abused or harmed an adult with care and support needs, or who may pose a risk of abuse to an adult with care and support needs, it is essential that the concerns are appropriately reported and responded to in accordance with the local safeguarding adults board multi-agency safeguarding adults policy and procedure.

Once the allegation has been reported it is important that the welfare and safety of adults (and children) is paramount, however, the trust should ensure that any staff member who has had an allegation made against them are treated proportionately, fairly and are provided with appropriate support. They should be kept fully informed of the progress of any investigation (unless sharing information would give rise to a risk, see above).

There may be several components to an allegation. This can be one or a combination of the following:

adult Safeguarding procedures (including a section 42 safeguarding enquiry)
LADO (where a person’s conduct towards an adult may impact on their suitability to work with or continue to work with children)
notify the police of the allegation
internal trust HR management investigation
not met the threshold for a PiPoT
no decision on the next steps until further clarity is received

A scoping meeting chaired by the PiPoT lead (or delegated person) should be convened as soon as practically possible following the disclosure of the allegation.

If the allegation is raised out of hours, then the matter should be escalated to on call manager.

See appendix C for the scoping meeting agenda.

The purpose of this meeting is to provide a decision-making framework in order to manage the allegation that has been raised.
The staff involved should be:

lead professional for safeguarding adults or nurse consultant for safeguarding
care group or corporate director (or representative)
people experience team representative
alleged individual’s line manager
administration support (for example, note taker)

5.4 Purpose of the scoping meeting

Is to:

determine whether the PiPoT threshold has been met
the process that will be followed
identify an action plan with delegated responsibilities and time frame, including informing and support plan for individuals subject to the PiPoT
if there is public interest then the trust’s Communication team should be informed to manage any potential publicity matters
if, at the scoping meeting, it is determined that a criminal act may have occurred then the subsequent investigations may be suspended until the police confirm that these investigations can commence, but permission to commence our own internal investigations is not required
from the police. An individual should be appointed to regularly liaise with the police to ensure that the investigation proceeds in a timely manner. Updates should be reported back to the PiPoT Lead, to ensure that no delays occur
risk assessment and management
redeployment or suspension
referral to the professional body if deemed appropriate at this time
CQC notification

5.5 Support for the person against whom an allegation has been made

Alongside the trust’s duty of care towards any individuals who are (potentially) at risk, the trust has a duty of care to the employee against whom the allegation has been brought. Support should be provided to minimise any potential stress associated with the process, which could usually include:

supporting the individual to understand the procedures being followed and any investigations being carried out
providing updates on developments of any procedures or investigations
giving the individual an opportunity to respond to allegations or concerns
supporting the individual to raise questions or concerns about their circumstances
referring the individual to occupational health
advising the individual that he or she may wish to seek support from their union or professional body, or independent advice. It should be noted that in some cases, limited information may only be able to be shared in order not to prejudice any enquiry, investigation or place anyone at risk

5.6 Conclusion of case

The PiPoT meeting will reconvene following the conclusion of any open investigation. The outcome will be:

false, there is insufficient evidence to either prove or disprove the allegation. The term therefore does not imply guilt or innocence
unsubstantiated, there is sufficient evidence to disprove the allegation
malicious, there is sufficient evidence to disprove the allegation and there has been a deliberate act to deceive
substantiated-there is sufficient evidence to prove the allegation

(Standard of proof is the balance of probability, not beyond reasonable doubt).

Recommendations will be made in respect of any further actions associated with the individual subject to the PiPoT including:

no further action
referral to professional body
referral to DBS
action plan in place (including, informal or support requirements)
performance responsibility framework
informing involved partner agencies
additional training requirement
duty of candour

If the PiPoT is removed by either being dismissed or permanently redeployed to a non-regulated activity because they pose a risk of harm to adults with care and support needs, the employer has a legal duty to refer the person to the disclosure and barring service (DBS). In addition, where appropriate, employers should report workers to the statutory and other bodies responsible for professional regulation such as the general medical council and the nursing and midwifery council. The individual must be informed of any action undertaken against them.

If a person subject to a PiPoT investigation attempts to leave their employment by resigning in an effort to avoid the investigation or disciplinary process, the employer is entitled not to accept that resignation, conclude whatever process has been utilised and, if the outcome warrants it, dismiss the employee or volunteer instead. This would also be the case where the person intends to take up legitimate employment or a course of study. A referral to DBS must be made if it is not possible to complete the disciplinary process.

The outcome will be documented on the PiPoT closure form (appendix D).

6 Lesson learned

The nurse consultant and representatives from the Safeguarding team will review any key themes and trends from the PiPoT meetings and ensure that the learning is embedded into front line practice via ongoing training, supervision and sharing across the organisation through established groups.

7 Reporting to RDaSH boards and safeguarding adult board (SAB)

The nurse consultant and representatives from the Safeguarding team will ensure that data from PiPoT activity will be reported to the safeguarding assurance group on a quarterly basis and to the respective safeguarding adults boards as and when required.

8 Training implications

8.1 All staff

How often should this be undertaken: Induction then every three years as part of safeguarding adults L1 training.
Training delivered by whom: Safeguarding team.
Where are the records of attendance held: Electronic staff record.

9 Monitoring arrangement

9.1 Adherence to policy and process

How: Training.
Reported to: Adherence to policy and process
Frequency: Training.

9.2 Number of PiPoT cases

How: Safeguarding assurance group report.
Who by: Safeguarding team
Frequency: Number of PiPoT cases

10 Equality impact assessment screening

To download the equality impact assessment for this policy, please follow this link: Equality impact assessment.

10.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).

10.1.1 Indicate how this will be met

No issues have been identified in relation to this policy.

10.2 Mental capacity act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all colleagues working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected, and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

10.2.1 Indicate how this will be achieved

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).

11 Associated documents

This list is not exhaustive. Refer to trust intranet.

12 References

Care Act (2014) Section 42 to 47.

13 Appendices

13.1 Appendix A Decision making support tool for making a PIPOT referral

Consider: Has the person behaved in a way that has harmed or may have harmed an adult with care and support needs
No concern: No concerns of harm or potential harm
Some concerns, require further enquiry: Some concerns of harm or potential harm
Significant cause for concern: Serious harm or potential harm

Consider: Has the person possibly committed a criminal offence against or related to an adult at risk
No concern: No
Some concerns, No harm towards an adult with care and support needs but a crime has been committed
Significant cause for concern: Yes

Consider: Has the person behaved towards an adult at risk in a way which indicates unsuitability to work with adults with care and support needs
No concern: No
Some concerns, Yes
Significant cause for concern: Yes

Consider: Has the person behaved in a way that has harmed or may have harmed children which means their ability to provide a service to adults with care and support needs must be reviewed
No concern: No
Some concerns, Yes
Significant cause for concern: Yes

Consider: Has the person behaved in a way which questions their ability to provide a service to adults with care and support needs which must be reviewed, for example; conviction for assault outside the work environment
No concern: No
Some concerns, Yes
Significant cause for concern: Yes

13.2 Appendix B Person in a position of trust (PiPoT) referral form

Appendix B Person in a position of trust (PiPoT) referral form

13.3 Appendix C Allegations against a person in a position of trust (PiPoT)

13.3.1 What is a PiPoT?

The Care Act 2014 and supporting care and support Statutory guidance requires local authorities and partner agencies (Including health providers) to have in place a framework and process for the management of allegations against “people in a position of trust”.

The meaning of the term people in a position of trust is “people who work in either a paid or unpaid capacity with adults with care and support needs.

A PiPoT is at risk of allegations being made against them at any time and, as an organisation, we need to ensure clear and safe working practices are in place. An allegation against a PiPoT must be taken seriously and dealt with in a way that protects both the adult and the PiPoT

12.3.2 PiPoT referral criteria

A PiPoT referral should be made of any allegations that have been made which indicates they may pose a risk to adult with care and support needs because in their work environment or in their life outside of work they are alleged to have;

behaved in a way that has harmed or may have harmed an adult with care and support needs
possibly committed a criminal offence against or related to an adult at risk
behaved towards an adult at risk in a way which indicates unsuitability to work with adults with care and support needs
behaved in a way that has harmed or may have harmed children which means their ability to provide a service to adults with care and support needs must be reviewed
behaved in a way which questions their ability to provide a service to adults with care and support needs which must be reviewed for example, conviction for assault outside the work environment

The referral criteria applies whether the allegation or concern is current or historical.

If a risk to children is identified then the local authority designated officer (LADO) is to be notified.

13.3.3 Safeguarding enquiry

Safeguarding duties apply to adults who:

has needs for care and support (whether or not the Local Authority is meeting these needs)
is experiencing or at risk of abuse or neglect
as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

An adult with care and support needs who has alleged to have been harmed will need to be subject to safeguarding procedures. The focus of the safeguarding enquiry will be the adult. Any immediate safeguarding concerns will need to be addressed by the employer.

13.3.3.1 The Safeguarding process will run alongside the PiPoT process

The employer should not ask any questions that would interfere with a criminal investigation. However, the PiPoT should be informed of concerns or allegations as soon as possible.

There are occasions when concerns, incidents or allegation are reported and do not involve an adult at risk or with care and support needs but indicate a potential risk of harm occurring. On these occasions the PiPoT process should be followed.

13.3.4 PiPoT referral process

A PiPoT referral form should be completed and sent to the RDaSH Safeguarding Adults team via email rdash.safeguardingadults@nhs.net

On receipt of the referral and a fully completed scoping tool, a PiPoT scoping meeting will be convened ASAP. The need for a formal meeting will be decided on a case by case basis depending on what further action is required.

In each case balance between the duty to protect the adult with care and support needs from harm and abuse and the effect on the adult from information about them being shared is required (for example Article 8 human rights, right to private family life) this may include a referral to the police if it is believed a crime has been committed.

Any HR management investigation should be conducted alongside the adult safeguarding policy and procedures and any police investigation. A police investigation will take priority over other investigations. Internal investigations and safeguarding enquiries may run concurrently.

13.4 Appendix D Agenda for PiPoT meeting

Appendix D Agenda for PiPoT meeting

13.5 Appendix E PiPoT Closure Form

Appendix E PiPoT closure form

13.6 Appendix F summary of PiPoT process

Concern raised (by staff member, patient, partner agency, LADO, member of the public, the list is not exhaustive)
Safeguarding team to be notified, PiPoT referral form to be completed and forwarded to rdash.safeguardingadults@nhs.net
Safeguarding team to arrange for a PiPoT initial scoping meeting to be convened
PiPoT Outcome meeting to be convened. To review the findings of any investigation, enquiry or disciplinary process. One of the following outcomes should be clearly documented in order to conclude the process:
- false
- unsubstantiated
- malicious
- substantiated
Nurse consultant to review any key learning points and disseminate to the deputy director of nursing and to all care group senior management teams
PiPoT data to be reported to the respective SAB on a quarterly basis and RDaSH safeguarding assurance group

Document control

Version: 2.
Unique reference number: 502.
Approved by: Clinical policies review and approvals group.
Date approved: 7 June 2022.
Name of originator or author: Lead professional or nurse consultant safeguarding.
Name of responsible individual: Safeguarding nurse consultant.
Date issued: 13 June 2022.
Review date: June 2025.
Target audience: All staff within the trust.

Page last reviewed: April 24, 2024
Next review due: April 24, 2025

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