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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Missing Service User Response and Safeguarding Policy

1. Purpose

The purpose of this policy is to ensure that in the event of a missing service user (person we support), the response is swift, coordinated, and effective to ensure their safety and well-being. This policy outlines the responsibilities of staff and the procedures for preventing, managing, and reporting incidents of missing service users.

This policy also incorporates safeguarding principles to prevent harm, comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and uphold CQC’s Fundamental Standards.

2. Scope

This policy applies to:

• All staff, volunteers, and agency workers at {{org_field_name}}.
• People we support, their families, and representatives.
• Third-party agencies involved in the care and safety of people we support.

3. Related Policies

This policy should be read in conjunction with:

• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy​.
• CH11 – Safe Care and Treatment Policy​.
• CH18 – Risk Management and Assessment Policy.
• CH19 – Emergency and Business Continuity Plan.
• CH24 – Management of Accidents, Incidents, and Near Misses Policy.
• CH25 – Notification of Other Incidents Policy​.
• CH35 – Duty of Candour Policy​.

4. Definitions

For the purposes of this policy:

• Missing Person: A person we support whose whereabouts cannot be established and where the circumstances give rise to concern for their safety or welfare. A person must not be regarded as missing solely because they have chosen to leave the care home or exercise their freedom of movement where they have capacity to make that decision and there is no reasonable cause for concern about their safety or welfare.
• Person at Increased Risk if Missing: A person whose individual circumstances mean that they may be at increased risk of harm if their whereabouts become unknown. Relevant factors may include, but are not limited to, cognitive impairment, dementia, learning disability, autism, mental health needs, physical frailty, communication difficulties, risk of falls, dependence on essential medication or treatment, risk of self-harm, previous missing episodes, risk of exploitation, abuse or coercion, inability to recognise danger, environmental conditions and any other factor identified through individual assessment.
• Safeguarding Concern: A concern that a person is experiencing, or is at risk of, abuse or neglect. A missing-person incident may give rise to a safeguarding concern where the circumstances indicate abuse, neglect, exploitation, coercion, organisational abuse, acts of omission or another safeguarding risk.
• Restriction: Any measure that limits a person’s freedom of movement or ability to make choices about where they go or what they do. Any restriction must have a lawful basis, be necessary and proportionate to the identified risk and be the least restrictive available option.
• Deprivation of Liberty: Circumstances amounting to a deprivation of liberty within Article 5 of the European Convention on Human Rights and the law applicable in England at the relevant time. Where a person may be deprived of their liberty, the care home must ensure that appropriate lawful authority is obtained and that the requirements of the Mental Capacity Act 2005 and any applicable Deprivation of Liberty Safeguards are followed.

5. Prevention Measures

{{org_field_name}} will take proportionate and person-centred measures to reduce the risk of a person becoming missing while respecting the person’s rights, independence, dignity, choices and freedom of movement.

The following requirements apply:

• Individual Risk Assessment: On admission, and whenever a person’s needs or circumstances change, an individual assessment must identify whether there is a foreseeable risk of the person becoming missing and the potential consequences if this occurs. The assessment must consider the person’s individual abilities, wishes, communication needs, capacity, health conditions, medication requirements, previous missing episodes, likely destinations, known routines, relationships, vulnerabilities and any safeguarding concerns.
• Regular Review: Missing-person risk assessments must be reviewed at planned intervals and promptly following any missing or near-missing incident, significant change in need, change in behaviour or other information indicating that the level or nature of risk may have changed.
• Personalised Prevention and Response Plan: Where a foreseeable risk is identified, the care plan and risk assessment must clearly state the measures required to reduce that risk and the actions staff must take if the person’s whereabouts cannot be established. Measures must be individually assessed and must not amount to a blanket restriction applied because of age, diagnosis or disability.
• Information for an Emergency: Where a person is assessed as being at risk of becoming missing, appropriate information that may assist an emergency search must be readily accessible to authorised staff. This should include, where available and relevant, an up-to-date photograph, physical description, usual clothing, communication needs, medical conditions, essential medication, mobility needs, places the person is known to visit, previous missing locations and appropriate family or representative contact details. Information must be stored and shared securely and only to the extent necessary for the person’s safety.
• Freedom of Movement and Restrictive Measures: Doors, exits, access controls, alarms and other security measures must not be used to impose an unlawful or disproportionate restriction on a person’s freedom of movement. Any restriction must be based on an individual assessment, be necessary and proportionate to the identified risk, and be the least restrictive available option.
• Mental Capacity: A person’s capacity must be presumed unless there is reason to doubt it. Where a specific decision relating to restrictions, supervision, surveillance or freedom of movement is required and there is reason to doubt capacity, a decision-specific capacity assessment must be completed in accordance with the Mental Capacity Act 2005. Where the person lacks capacity, any decision made on their behalf must be made in their best interests and must have regard to the least restrictive option.
• Deprivation of Liberty: Where care arrangements may amount to a deprivation of liberty, the Registered Manager must ensure that the current legal test is considered and that appropriate lawful authority is obtained where required. Staff must follow the Mental Capacity Act 2005, applicable Deprivation of Liberty Safeguards requirements, current CQC and government guidance and relevant case law.
• Assistive Technology and Surveillance: GPS devices, location-monitoring equipment, door sensors, CCTV or other monitoring technology may only be used where there is a clear and documented purpose, the measure is necessary and proportionate, and consent or another lawful basis is established. Where a person lacks capacity to consent to the particular measure, a decision-specific capacity assessment and properly recorded best-interests decision must be completed where applicable. Monitoring must not be used as a substitute for appropriate staffing, supervision or person-centred care.
• Staff Knowledge and Training: Staff must understand each person’s individual missing-person risk and response plan and must receive appropriate training in risk assessment, safeguarding, the Mental Capacity Act 2005, lawful restrictions, escalation procedures and the actions required when a person cannot be located.

6. Immediate Response Procedure

6.1 Immediate Actions

As soon as a member of staff becomes aware that a person’s whereabouts cannot be established, they must immediately inform the senior member of staff on duty.

The senior member of staff must immediately review the person’s individual care plan, missing-person risk assessment and the circumstances of the incident and determine the level and immediacy of risk.

Where there is a real and immediate risk to life, serious harm or another emergency, staff must contact the police using 999 without delay. Searching the premises or contacting relatives must not delay an emergency police report.

Where there is no immediate risk requiring a 999 response, staff must take prompt and proportionate steps to establish the person’s whereabouts. These may include:

• checking the person’s bedroom, toilets, bathrooms, communal areas, gardens, outbuildings and other areas of the premises;
• confirming whether the person is attending a planned appointment, activity, visit or outing;
• checking signing-out records and other relevant records;
• checking information from staff and other people who may have seen the person;
• checking authorised door-access, alarm or CCTV information where this is lawful and available;
• contacting relevant family members, representatives or known contacts where appropriate;
• checking immediately accessible places that the person is known to frequent, where this can be done safely and without compromising the safety of other people using the service; and
• reviewing the person’s known risks, likely destinations, communication needs, essential medication requirements and any circumstances that may increase the risk of harm.

All actions and the times at which they are taken must be recorded contemporaneously.

6.2 Reporting the Person to the Police

There must be no fixed waiting period before contacting the police.

The person must be reported to the police without delay where:

• there is a real or immediate risk to life or serious harm;
• the person’s individual risk assessment identifies that becoming missing presents a significant risk;
• the person is unable to protect themselves from foreseeable harm;
• essential medication, treatment or care has been missed or is likely to be missed and this creates a significant risk;
• there is concern about abuse, neglect, exploitation, coercion, self-harm or criminal activity;
• weather, environmental or other conditions create increased risk;
• the circumstances are significantly out of character or otherwise give rise to concern for the person’s safety; or
• reasonable and proportionate enquiries have failed to establish the person’s whereabouts and the circumstances meet the threshold for a missing-person report.

Staff must call 999 where an emergency police response is required. Where the circumstances require police involvement but there is no immediate emergency, staff must use 101 or the locally agreed police reporting route.

When reporting a person missing, staff must provide the police with all relevant available information, including:

• full name and preferred name;
• age and date of birth;
• an up-to-date physical description and recent photograph where available;
• clothing and footwear;
• time and place last seen;
• medical conditions;
• essential medication and the consequences of missed medication;
• cognitive, communication or sensory needs;
• mobility needs;
• identified risks and vulnerabilities;
• known places, routes or addresses the person may visit;
• relevant previous missing episodes;
• relevant family members, friends or other contacts;
• access to money, transport or a mobile telephone where known;
• any safeguarding concerns, including suspected abuse, exploitation or coercion; and
• all searches and enquiries already undertaken.

The police incident or reference number must be obtained and recorded.

6.3 Internal and External Escalation

The Registered Manager, or the designated senior manager where the Registered Manager is unavailable, must be informed as soon as practicable and without unnecessary delay.

Staff must follow the organisation’s management escalation arrangements, including the appropriate out-of-hours arrangements.

The family, representative or next of kin must be informed where appropriate, taking account of the person’s wishes, confidentiality, capacity, best interests, safeguarding considerations and any police advice.

Where the circumstances indicate that the person is experiencing, or is at risk of, abuse or neglect and may be unable to protect themselves because of their care and support needs, a safeguarding concern must be raised with the relevant local authority in accordance with local safeguarding procedures.

Where the circumstances meet the criteria for a notification to the Care Quality Commission, the Registered Person must ensure that the required CQC notification is submitted without delay in accordance with the Care Quality Commission (Registration) Regulations 2009.

Staff must continue to co-operate with the police and other relevant agencies and provide updated information as it becomes available. Staff-led searching outside the care home must only take place where it is safe, proportionate, consistent with the person’s individual plan and does not place other people using the service at risk through inadequate staffing or supervision.

Information must not be released to the media by staff. Any media request must be referred to the Registered Manager or other authorised senior person and managed in conjunction with police advice where the police are involved.

7. Post-Incident Actions

When the person is located or returns to the care home, staff must ensure that the response is person-centred, supportive and proportionate.

The following actions must be taken:

• Immediate Welfare Assessment: The person’s physical and emotional wellbeing must be assessed promptly. Any injury, illness, distress, exposure, dehydration, missed medication or other health concern must be addressed without delay and appropriate clinical or emergency assistance obtained where required.
• Police Update: Where the person has been reported missing to the police, the police must be informed promptly when the person has been located or returned. The time of the person’s return or recovery and any instructions received from the police must be recorded.
• Listen to the Person: Where practicable, the person must be given an opportunity to explain where they went, what happened while they were away, why they left and whether they experienced harm, abuse, neglect, exploitation, coercion or distress. Communication support, advocacy or other reasonable adjustments must be provided where required.
• Safeguarding Action: Any disclosure, allegation, indication or reasonable suspicion of abuse, neglect, exploitation, coercion or other safeguarding concern must be acted upon immediately in accordance with the Safeguarding Adults from Abuse and Improper Treatment Policy and local safeguarding procedures. Relevant evidence must be preserved and unnecessary questioning must be avoided where this could compromise a police or safeguarding investigation.
• Incident Recording: A complete and contemporaneous record must be made of the incident, including when the person was last seen, when their absence was identified, searches undertaken, risk decisions, persons contacted, police involvement and reference number, safeguarding referrals, CQC notifications where applicable, time and circumstances of return, welfare observations and actions taken.
• Care Plan and Risk Assessment Review: The person’s care plan, missing-person risk assessment and any relevant support plans must be reviewed promptly. The review must take account of what happened, the person’s views and wishes, any newly identified risks, previous incidents and lessons from the event.
• Mental Capacity and Restrictive Practice Review: Where restrictions, enhanced supervision, monitoring technology, locked doors or other measures are proposed or altered following the incident, these must not be imposed automatically. Capacity, consent, best interests, proportionality, necessity and the least restrictive alternative must be considered and recorded in accordance with the Mental Capacity Act 2005 and applicable deprivation of liberty requirements.
• Management Review and Learning: The Registered Manager or delegated competent person must review the incident to establish whether systems, staffing, supervision, risk assessment, communication, environmental arrangements or care planning contributed to the incident. Required improvements must be identified, implemented and monitored.
• Relevant Notifications: The Registered Manager must ensure that all legally required notifications and referrals, including notifications to CQC and safeguarding referrals where applicable, have been completed and recorded.

8. Reporting and Compliance

All missing-person incidents must be recorded in accordance with {{org_field_name}}’s incident-reporting and record-keeping procedures.

8.1 Care Quality Commission Notifications

The Registered Person is responsible for ensuring that notifications required by the Care Quality Commission (Registration) Regulations 2009 are made to CQC within the required timescale.

Under Regulation 18 of the Care Quality Commission (Registration) Regulations 2009, CQC must be notified without delay where a notifiable incident occurs while services are being provided in the carrying on of a regulated activity, or as a consequence of the carrying on of a regulated activity.

This includes, where applicable:

• any abuse or allegation of abuse in relation to a person using the service; and
• any incident which is reported to, or investigated by, the police.

Accordingly, where a missing-person incident is reported to, or investigated by, the police, the Registered Person must ensure that the appropriate CQC notification is submitted without delay.

The notification must be made using the method or form required by CQC at the relevant time. A record of the notification, the date submitted and any CQC reference must be retained.

A missing-person incident that has not been reported to or investigated by the police is not automatically notifiable to CQC solely because the person was temporarily unaccounted for. The Registered Manager must nevertheless consider whether another notification requirement applies, including where there is alleged or suspected abuse or another legally notifiable event.

8.2 Safeguarding Notifications

Where the circumstances indicate abuse, neglect, exploitation or another safeguarding concern, the service must raise the concern with the relevant local authority in accordance with the Care Act 2014 and applicable local safeguarding procedures.

Where the criteria in section 42 of the Care Act 2014 are engaged, this includes circumstances where the local authority has reasonable cause to suspect that an adult:

• has needs for care and support;
• is experiencing, or is at risk of, abuse or neglect; and
• as a result of those needs is unable to protect themselves against the abuse or neglect or the risk of it.

The service must co-operate with safeguarding enquiries and provide relevant information in accordance with its legal obligations.

8.3 Police Records

Where police have been contacted, the police incident or reference number, the time of contact, information supplied and relevant subsequent communication must be recorded.

8.4 Records, Review and Learning

Records relating to the incident must be accurate, complete, contemporaneous and securely maintained.

The Registered Manager must ensure that incidents are reviewed for patterns, recurring risks and learning. Where improvements are identified, actions must be allocated, completed and monitored.

Where the circumstances meet the statutory criteria for the duty of candour, the requirements of Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and {{org_field_name}}’s Duty of Candour Policy must be followed.

9. Safeguarding, Mental Capacity and Deprivation of Liberty

9.1 Safeguarding

A missing-person incident must be considered in the context of the person’s individual circumstances and must not automatically be treated as evidence of abuse or neglect.

However, where the incident gives rise to an allegation, disclosure, indication or reasonable suspicion of abuse, neglect, exploitation, coercion, organisational abuse or another safeguarding concern, staff must take immediate protective action and follow {{org_field_name}}’s safeguarding procedures and the relevant local authority safeguarding arrangements.

Where there is reasonable cause to suspect that an adult with care and support needs is experiencing, or is at risk of, abuse or neglect and, because of those needs, is unable to protect themselves from that abuse, neglect or risk, the concern must be referred to the relevant local authority in accordance with the Care Act 2014 and local safeguarding procedures.

9.2 Mental Capacity

The principles of the Mental Capacity Act 2005 must be followed whenever decisions are being made about a person’s freedom of movement, supervision, monitoring, restrictions or measures intended to prevent them leaving the care home.

A person must be presumed to have capacity unless it is established otherwise.

A person must not be treated as lacking capacity merely because they make a decision that staff, relatives or professionals consider unwise.

Where there is reason to doubt capacity, the assessment must relate to the specific decision that needs to be made at the relevant time.

Where a person lacks capacity to make the relevant decision, any decision made or action taken on their behalf must be in their best interests and must achieve its purpose in a way that is less restrictive of the person’s rights and freedom of action wherever this is reasonably practicable.

9.3 Restrictions and Deprivation of Liberty

Restrictions intended to reduce the likelihood of a person becoming missing must not be imposed solely because the person has dementia, a learning disability, a mental health condition, is older, has previously become missing or is considered vulnerable.

Any restriction must:

• have a clear and lawful basis;
• respond to an individually assessed risk;
• be necessary;
• be proportionate to the likelihood and seriousness of harm;
• represent the least restrictive reasonably practicable option;
• take account of the person’s wishes, feelings and preferences;
• be documented in the person’s care plan and risk assessment; and
• be reviewed regularly and whenever circumstances change.

A person must not be deprived of their liberty for the purpose of receiving care or treatment without lawful authority.

The Registered Manager must ensure that staff apply the law on deprivation of liberty that is current at the time of the decision, including the Mental Capacity Act 2005, applicable Deprivation of Liberty Safeguards requirements and relevant case law.

In particular, following the Supreme Court judgment of 2 June 2026 in A Reference by the Attorney General for Northern Ireland [2026] UKSC 16, the service must not rely solely on the former approach to determining deprivation of liberty. The person’s circumstances, wishes, feelings and response to the arrangements, together with the nature and degree of confinement and all other legally relevant factors, must be considered in accordance with the current law and current government, CQC and local authority guidance.

Where there is uncertainty as to whether arrangements amount to a deprivation of liberty or what authorisation is required, the Registered Manager must obtain appropriate advice and must not knowingly continue an unlawful deprivation of liberty.

Where a Deprivation of Liberty Safeguards application or other lawful authorisation is required, it must be pursued in accordance with the applicable statutory process. Any conditions attached to an authorisation must be implemented, monitored and recorded.

Any CQC notification required in connection with a deprivation of liberty application or its outcome must be completed in accordance with the Care Quality Commission (Registration) Regulations 2009 and current CQC notification requirements.

10. Policy Review

This policy will be reviewed annually or sooner if there are legislative changes, learning from incidents, or new best practice guidance.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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