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Maintaining Professional Boundaries Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} maintains clear professional boundaries between staff and the people we support, their families, and colleagues. Establishing and upholding these boundaries is essential for providing safe, person-centred, and ethical care while preventing conflicts of interest, safeguarding risks, and professional misconduct.

This policy ensures:

• Staff conduct themselves professionally and ethically in all interactions.
• Person-centred care is delivered with dignity, respect, and impartiality.
• The risk of abuse, exploitation, and inappropriate relationships is minimised.
• Compliance with CQC regulations, employment law, and safeguarding policies.
• Trust and transparency between people we support, their families, and staff.

2. Scope

This policy applies to:

• All employees, including full-time, part-time, agency, and voluntary workers.
• Managers and senior leaders, responsible for overseeing compliance.
• People we support, ensuring their safety and well-being.
• Families, advocates, and visitors, ensuring appropriate interactions with staff.

3. Legal and Regulatory Compliance

This policy must be implemented in accordance with the legislation, regulations and statutory requirements applicable to the service, including the following.

Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

• Regulation 9 – Person-centred care: Care and treatment must be appropriate, meet the person’s needs and reflect their preferences. People must be supported to participate in decisions about their care and treatment.
• Regulation 10 – Dignity and respect: People using the service must be treated with dignity and respect, including respect for their privacy, autonomy, independence, personal relationships and relevant protected characteristics.
• Regulation 11 – Need for consent: Care and treatment must only be provided with the consent of the relevant person, unless another lawful basis permits the care or treatment to be provided. Where a person aged 16 or over lacks capacity to make the relevant decision, staff must act in accordance with the Mental Capacity Act 2005.
• Regulation 12 – Safe care and treatment: Care and treatment must be provided safely. Risks to the health and safety of people using the service must be assessed and appropriate action taken to mitigate those risks.
• Regulation 13 – Safeguarding service users from abuse and improper treatment: People using the service must be protected from abuse and improper treatment. The service must operate effective systems and processes to prevent abuse and must investigate immediately upon becoming aware of any allegation or evidence of abuse. For the purposes of Regulation 13, abuse includes sexual abuse, physical or psychological ill-treatment, theft, misuse or misappropriation of money or property, and neglect.
• Regulation 17 – Good governance: Effective systems and processes must be operated to assess, monitor and mitigate risks, monitor and improve the quality and safety of the service and maintain accurate, complete, contemporaneous and secure records relating to people using the service, staff and the management of the regulated activity.
• Regulation 18 – Staffing: Staff must receive the support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties safely and competently.
• Regulation 19 – Fit and proper persons employed: Staff employed to carry on the regulated activity must be of good character and have the qualifications, competence, skills and experience necessary for their role. Recruitment and employment arrangements must continue to support compliance with these requirements.
• Regulation 20 – Duty of candour: The registered person must act in an open and transparent manner with people receiving care. Where a professional-boundary incident also constitutes a notifiable safety incident within Regulation 20, the statutory duty of candour procedure must be followed.

Care Quality Commission (Registration) Regulations 2009

• Regulation 18 – Notification of other incidents: The registered person must notify the Care Quality Commission without delay of abuse or an allegation of abuse in relation to a person using the service where the circumstances fall within the notification requirements of the Regulations. This includes relevant sexual abuse, physical or psychological ill-treatment, theft, misuse or misappropriation of money or property, and neglect or acts of omission causing harm or placing the person at risk of harm.

Other Relevant Legislation

• Care Act 2014: Safeguarding concerns involving an adult with care and support needs must be recognised, reported and managed in accordance with the Care Act 2014, associated statutory guidance and local safeguarding procedures. Staff must cooperate with safeguarding enquiries and other lawful safeguarding processes.
• Mental Capacity Act 2005: A person must be presumed to have capacity unless it is established otherwise. Staff must support people to make their own decisions wherever possible. Where a person lacks capacity for a particular decision, any action or decision taken on their behalf must comply with the Mental Capacity Act 2005, including the best-interests requirements and the requirement to consider the least restrictive option.
• Equality Act 2010: Staff must not discriminate unlawfully and must respect the protected characteristics, rights, choices and individual needs of people using the service.
• Sexual Offences Act 2003: Sexual conduct that constitutes an offence, including offences relating to people with a mental disorder where the statutory conditions are met, must be treated as a safeguarding matter and reported to the appropriate authorities in accordance with safeguarding procedures.
• Safeguarding Vulnerable Groups Act 2006: Where the legal conditions for referral to the Disclosure and Barring Service are met, the provider must make the required referral. This applies, for example, where a person working in regulated activity is removed from that activity, or would have been removed had they not left, because the statutory harm or risk-of-harm conditions are satisfied.
• UK General Data Protection Regulation and Data Protection Act 2018, as amended: Personal and special-category information, photographs, recordings, messages and other information relating to people using the service must only be obtained, accessed, used, stored and disclosed where there is a lawful basis and in accordance with applicable data-protection and confidentiality requirements.

Staff must also comply with relevant professional codes, contractual requirements, organisational policies and local safeguarding procedures applicable to their role.

4. Defining Professional Boundaries

Professional boundaries are clear guidelines that define appropriate interactions between staff and the people we support. Boundaries help ensure ethical, safe, and effective care. Key areas include:

4.1. Maintaining a Professional Relationship

Staff must:

• Treat all people we support with equal care, respect, and dignity.
• Avoid personal, financial, or social relationships that compromise professional integrity.
• Maintain confidentiality and avoid discussing personal matters unrelated to care.
• Not share personal contact details (e.g., phone number, email, social media).
• Avoid favouritism and ensure all people we support receive equal attention and care.

4.2. Personal Relationships with People We Support and Their Families

Staff must maintain relationships with people using the service that are appropriate to their professional role and must not exploit the trust, dependence, vulnerability or authority arising from that role.

Staff must not:

• engage in a sexual or romantic relationship with a person using the service;
• engage in sexualised behaviour, sexual communication or inappropriate intimate contact with a person using the service;
• encourage or knowingly develop a relationship with a person using the service that is exploitative, secretive, coercive or otherwise inconsistent with the staff member’s professional responsibilities;
• solicit gifts, money, loans, financial benefits, hospitality, services or personal favours from a person using the service or from somebody acting on their behalf;
• lend money to, or borrow money from, a person using the service;
• use a person’s property, possessions, bank account, payment card, benefits, loyalty points or other financial resources for the staff member’s own benefit;
• place pressure on a person in relation to gifts, wills, inheritance, property or other financial arrangements; or
• enter into a private business, financial or commercial arrangement with a person using the service.

Any unsolicited token gift offered to a member of staff must be dealt with in accordance with the organisation’s gifts and hospitality procedure. Cash and cash-equivalent gifts must not be accepted. Any gift that is permitted under the organisation’s procedure must be declared and recorded so that the service can identify and manage any actual or potential conflict of interest, exploitation or safeguarding risk.

Where a person using the service develops romantic or sexual feelings towards a member of staff, or seeks a relationship that could compromise professional boundaries, the member of staff must not reciprocate or exploit those feelings. The staff member must inform their line manager or the Registered Manager so that the situation can be managed sensitively, lawfully and in a way that respects the person’s dignity and rights.

Relationships with relatives, representatives or others connected with a person using the service must not be allowed to influence the care provided, compromise confidentiality, create a conflict of interest or expose the person using the service to abuse, neglect or exploitation.

4.3. Physical Contact, Personal Care and Consent

Physical contact must only take place where it is appropriate to the person’s assessed care and support needs, necessary for the task being undertaken or otherwise freely initiated or agreed by the person in circumstances that are consistent with professional boundaries.

Staff must respect each person’s privacy, dignity, personal space, cultural needs, communication needs, preferences and right to refuse care or physical contact.

Before providing personal or intimate care, staff must:

• explain what they propose to do in a way the person can understand;
• seek and obtain the person’s valid consent before proceeding;
• remain alert to verbal and non-verbal indications that the person wishes the care or contact to stop;
• respect a withdrawal of consent and stop the intervention unless there is a separate lawful authority for continuing;
• provide privacy and protect the person’s dignity;
• follow the person’s care plan and relevant risk assessments; and
• record relevant consent decisions, refusals and significant changes in accordance with the service’s record-keeping requirements.

Consent may be communicated verbally, non-verbally or by another valid means appropriate to the person and the particular decision. Staff must not assume consent merely because a person has previously accepted the same care.

A person must be presumed to have capacity to make a decision unless it is established, in accordance with the Mental Capacity Act 2005, that they lack capacity to make that particular decision at the particular time.

Where there is reason to doubt a person’s capacity to consent to the proposed care or contact, staff must follow the Mental Capacity Act 2005 and the organisation’s Mental Capacity Act procedures. Where the person lacks capacity, any decision or act undertaken on their behalf must have a lawful basis, be in their best interests where the Mental Capacity Act 2005 requires this, and be the least restrictive appropriate option.

A chaperone or second member of staff must be used where this is required by an assessed risk, the person’s care plan, the person’s wishes, the nature of the intervention or another applicable procedure. The presence of another member of staff does not remove the requirement for valid consent or other lawful authority.

4.4. Financial and Legal Boundaries

Staff must protect people using the service from financial or material abuse, exploitation, theft, fraud, coercion, misuse or misappropriation of money or property.

Staff must not:

• borrow money from or lend money to a person using the service;
• accept cash, cash-equivalent gifts or personal financial benefits from a person using the service;
• use a person’s money, bank card, account, PIN, possessions, benefits or property for the staff member’s own purposes;
• make purchases for themselves using a person’s money;
• persuade, pressure, encourage or influence a person to make a gift, loan, payment or financial arrangement for the benefit of the staff member or another person;
• become a beneficiary under a person’s will as a consequence of the professional relationship;
• encourage or influence a person to amend a will, inheritance arrangement, property ownership or other financial arrangement;
• act as an attorney under a lasting or enduring power of attorney, deputy, appointee, executor, trustee or other financial representative for a person using the service where this would arise from or conflict with the staff member’s professional relationship;
• witness a will or other personal legal document for a person using the service in circumstances prohibited by organisational procedure or where doing so could create a conflict of interest, safeguarding concern or question regarding undue influence; or
• make financial decisions on behalf of a person unless there is specific lawful authority to do so.

Where the service has formally agreed to provide support with a person’s money or property, this must only be undertaken:

• in accordance with the person’s assessed needs, wishes and care plan;
• with valid consent or other lawful authority;
• by staff who are authorised and competent to undertake the task;
• in accordance with the organisation’s financial procedures;
• with accurate records, receipts and an appropriate audit trail; and
• with appropriate safeguards against theft, fraud, coercion, exploitation and misuse.

Any unexplained financial transaction, missing money or property, suspected misuse of a person’s finances, inappropriate gift, suspected undue influence or other financial-boundary concern must be reported immediately in accordance with the safeguarding procedure.

4.5. Social Media and Online Communication

• Staff must not connect with people we support or their families via social media.
• No photographs, videos, or personal information should be shared without explicit, documented consent.
• Staff must not discuss work-related matters on social media, maintaining confidentiality.
• Complaints or grievances must be reported internally, not posted online.

4.6. Lone Working and One-to-One Care

• Lone working must be risk assessed, and clear procedures followed.
• Staff providing one-to-one care should always:
  • Maintain professional behaviour.
  • Keep records of care interactions.
  • Report any concerns regarding inappropriate expectations or requests.

4.7. Safeguarding and Reporting Boundary Violations

Any concern that a member of staff, agency worker, volunteer, professional or other person has crossed a professional boundary must be taken seriously and responded to according to the nature, seriousness and risk of the concern.

Staff must immediately report any suspected, witnessed, disclosed or alleged professional-boundary breach that may involve abuse, neglect, exploitation, improper treatment, coercion, inappropriate sexual behaviour, misuse of money or property or another safeguarding risk to the Registered Manager, Safeguarding Lead or other manager identified in the organisation’s safeguarding procedure.

If the person to whom the concern would normally be reported is implicated in the concern, or if the staff member reasonably believes the concern is not being dealt with appropriately, the staff member must use the organisation’s escalation and whistleblowing arrangements and may raise the matter directly with the appropriate external authority.

On receiving a concern, the Registered Manager or responsible manager must:

• take immediate and proportionate action to protect the person using the service and any other person who may be at risk;
• arrange appropriate medical attention, emergency assistance or police involvement where required;
• ensure that the allegation, disclosure, observed facts and actions taken are recorded accurately and contemporaneously;
• preserve relevant records, messages, photographs, CCTV, financial records or other evidence where appropriate;
• determine whether the matter constitutes a safeguarding concern and make the required referral or notification to the relevant local authority safeguarding service in accordance with the Care Act 2014 and local safeguarding procedures;
• ensure that any allegation or evidence of abuse is addressed immediately through the organisation’s safeguarding and investigation procedures, while avoiding action that could compromise a police or local-authority safeguarding investigation;
• notify the Care Quality Commission without delay where the incident or allegation falls within Regulation 18 of the Care Quality Commission (Registration) Regulations 2009;
• consider whether the police or another statutory body must be informed;
• consider whether the staff member should be removed from particular duties, redeployed or suspended while enquiries are undertaken, based on the assessed risk and in accordance with employment procedures;
• consider whether a referral to the Disclosure and Barring Service is legally required;
• consider whether a referral or notification is required to a professional regulator; and
• consider whether the statutory duty of candour applies.

A person using the service must be listened to, taken seriously and supported throughout the process. Their immediate safety, dignity, communication needs, wishes and feelings must be considered. Information must be shared on a lawful and proportionate basis with those who need it for safeguarding, investigation or regulatory purposes.

Staff must not:

• promise to keep a disclosure of abuse secret;
• confront an alleged perpetrator where doing so may increase risk or prejudice an investigation;
• conduct their own unauthorised investigation;
• delete, alter or conceal relevant records or communications; or
• discourage a person from raising a concern or contacting the police, local authority, CQC, an advocate or another appropriate body.

All professional-boundary concerns must be documented factually and without speculation. Records must clearly distinguish between what was observed, what was reported by another person, and any action or decision subsequently taken.

5. Staff Training and Awareness

The provider must ensure that staff receive the training, support, supervision, professional development and appraisal necessary to enable them to perform their duties safely, competently and in accordance with this policy.

All relevant staff must receive appropriate instruction and training on:

• professional boundaries and expected standards of conduct;
• safeguarding adults and recognising abuse, neglect and exploitation;
• responding to disclosures, allegations and safeguarding concerns;
• consent and the Mental Capacity Act 2005 as relevant to their role;
• privacy, dignity and confidentiality;
• financial abuse and appropriate financial boundaries;
• appropriate physical contact and intimate care;
• use of electronic communication, photographs, recordings and social media;
• reporting concerns, whistleblowing and escalation procedures; and
• the circumstances in which external safeguarding, regulatory or statutory notifications may be required.

Training must be appropriate to the staff member’s role and responsibilities. The provider must determine the need for refresher or additional training by considering the person’s role, competence, supervision, incidents, identified risks, changes in legislation or guidance and any learning identified through audits, safeguarding concerns, complaints or investigations.

Managers must use supervision, appraisal, observation of practice and other appropriate competency-assurance processes to identify whether staff understand and apply professional-boundary requirements in practice.

Where a concern, incident or audit identifies a gap in a staff member’s knowledge or competence, appropriate retraining, supervision, competency assessment or other management action must be undertaken without unnecessary delay.

Training and competency records must be maintained securely and must provide sufficient evidence that staff have received the training, support and supervision required for their role.

6. Managing and Responding to Boundary Violations

All professional-boundary concerns must be assessed according to the conduct involved, the impact or potential impact on the person using the service, the level of risk, whether abuse or improper treatment may have occurred, whether the behaviour is repeated or deliberate and whether a statutory or regulatory response is required.

The fact that a member of staff states that a breach was accidental, well-intentioned or unintentional must not prevent safeguarding action where the circumstances indicate that a person may have experienced or been placed at risk of abuse, neglect, exploitation or improper treatment.

6.1. Lower-Risk Boundary Concerns

Where a concern does not constitute suspected abuse, neglect, exploitation or improper treatment and does not create an immediate safeguarding risk, the manager must:

• establish and record the relevant facts;
• assess any impact or potential risk to the person using the service;
• discuss the concern with the staff member;
• provide clear instruction about the professional standard required;
• consider whether additional training, supervision or competency assessment is required;
• consider whether formal management or disciplinary action is required under the organisation’s procedures; and
• monitor subsequent practice where appropriate.

Any repeated boundary concern must be reviewed to determine whether it indicates a wider conduct, competence, safeguarding or governance concern.

6.2. Serious Boundary Breaches and Safeguarding Concerns

Where a professional-boundary concern may constitute abuse, neglect, exploitation, improper treatment, sexual misconduct, financial abuse, significant misuse of confidential information or another serious risk, the safeguarding procedure must be initiated immediately.

The provider must:

• take immediate and proportionate measures to protect people who may be at risk;
• make required safeguarding referrals and statutory notifications;
• notify CQC without delay where required under the Care Quality Commission (Registration) Regulations 2009;
• consider police involvement where a criminal offence may have occurred;
• take appropriate action regarding the staff member’s duties while enquiries are undertaken;
• follow a fair disciplinary process where employment action is required;
• make a Disclosure and Barring Service referral where the statutory referral conditions are met;
• make any required referral or notification to the staff member’s professional regulator;
• comply with the statutory duty of candour where applicable;
• maintain accurate and contemporaneous records of the concern, risk assessment, decisions, referrals, notifications and actions taken; and
• identify and implement any organisational learning necessary to prevent recurrence.

Dismissal, resignation, retirement, redeployment, transfer to another role or the expiry of an agency or temporary arrangement must not be used to avoid a safeguarding investigation or a referral to the Disclosure and Barring Service where the legal referral conditions are met.

The service must cooperate with CQC, the local authority, the police, the Disclosure and Barring Service, professional regulators and other statutory bodies where legally required.

7. Monitoring and Compliance

The Registered Provider and Registered Manager must maintain effective governance arrangements to monitor compliance with this policy and identify, assess and reduce professional-boundary risks.

Monitoring arrangements must include, where relevant:

• review of professional-boundary concerns, safeguarding incidents, allegations and complaints;
• review of relevant disciplinary and whistleblowing concerns;
• monitoring of staff supervision, training and competency;
• review of gifts, financial transactions or financial-support records where the service is involved in managing or supporting a person’s money;
• review of incidents involving inappropriate communication, photographs, recordings or social-media contact;
• review of recurring concerns involving individual staff members, people using the service, particular teams or particular working arrangements;
• assessment of whether statutory safeguarding referrals, CQC notifications, Disclosure and Barring Service referrals or professional-regulator referrals were made when required;
• audits of relevant records to ensure that they are accurate, complete, contemporaneous and securely maintained; and
• implementation and monitoring of action plans arising from identified concerns.

The frequency and scope of monitoring must be proportionate to the risks identified. Serious incidents and emerging safeguarding risks must be reviewed without waiting for a scheduled audit or quarterly review.

Managers must identify themes, trends and repeated concerns and must take action where monitoring identifies weaknesses in staff practice, training, supervision, risk management, reporting or governance.

Learning arising from incidents, complaints, safeguarding enquiries, regulatory findings and audits must be used to improve practice, policies, staff training and risk controls.

Records of audits, reviews, decisions, identified risks and improvement actions must be maintained in accordance with Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

8. Related Policies

This policy must be read alongside the organisation’s relevant policies and procedures, including:

• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy;
• CH27 – Staff Supervision, Training and Development Policy;
• CH28 – Staff Conduct and Code of Ethics Policy;
• CH34 – Confidentiality and Data Protection Policy;
• CH10 – Using Social Media Platforms Policy;
• Mental Capacity Act and Consent Policy;
• Whistleblowing Policy;
• Gifts, Hospitality and Conflicts of Interest Policy or Procedure;
• Service Users’ Money and Financial Arrangements Policy, where applicable;
• Incident and Accident Reporting Policy;
• Duty of Candour Policy;
• Recruitment and Disclosure and Barring Service Policy;
• Disciplinary Policy; and
• Complaints Policy.

Where the organisation uses different policy titles or reference numbers, the corresponding current policy must be identified in this section.

9. Policy Review

This policy will be reviewed annually, or sooner if:

• CQC regulations change.
• Staff feedback suggests improvements.
• Serious incidents require updates.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
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