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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Out of Hours Policy

Purpose

This policy sets out how we manage and respond to care-related issues outside standard office hours so that people continue to receive safe, effective and responsive care at all times. It supports compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (including, where relevant, Regulations on person-centred care, dignity and respect, consent, safeguarding, safe care and treatment, staffing, complaints, good governance and duty of candour) and CQC’s assessment approach under the Single Assessment Framework.

{{org_field_name}} is registered with the Care Quality Commission to carry out the regulated activity of {{org_field_regulated_activity}} for {{org_field_service_users_bands}} in their own homes.

Scope
This policy applies to all staff, clients, their families, and external professionals involved in our care service.

Standard Office Hours
Our office is open:
Monday to Friday: 9:00am – 5:00pm

Out of Hours Service
Our out of hours service is in place to provide continuous support and ensure that urgent care matters are dealt with promptly and appropriately. The service covers:

• Weekdays: 5:00pm – 9:00am
• Weekends: from 5:00pm on Friday to 9:00am on Monday
• All bank holidays and public holidays
  
  

Out of Hours Contact Number:
{{org_field_out_of_hours}}

Key Principles

1. Safety First
   • We prioritise the health, safety, and wellbeing of our clients and staff at all times, ensuring urgent needs are addressed without delay.
2. Responsiveness
   • All out of hours calls will be responded to promptly, with clear advice and action to resolve issues or minimise risks.

Response time standard

• All out of hours calls must be answered or returned within 15 minutes (or sooner where risk indicates).
• Where immediate risk to life is present, staff must call 999 first and then inform the out of hours manager.
• If the out of hours manager cannot be reached within 15 minutes, staff must escalate to the second on-call contact / senior manager (as per the on-call rota).
• All response and escalation times must be recorded in the out of hours log.

3. Confidentiality and Respect
   • All discussions and information shared are treated confidentially and respectfully, in line with data protection and safeguarding requirements.
4. Regulatory Compliance
   • Our out of hours arrangements support compliance with the CQC Single Assessment Framework and the Fundamental Standards. We evidence how we meet the 5 key questions (Safe, Effective, Caring, Responsive, Well-led) using CQC Quality Statements (which replace KLOEs). Evidence includes (but is not limited to): incident logs, escalation records, staffing contingency actions, safeguarding actions, duty of candour records, and lessons-learned reviews.

CQC statutory notifications (out of hours reporting)

Where an out of hours incident meets the criteria for a CQC statutory notification, we will notify CQC within the required timescales and in line with the Care Quality Commission (Registration) Regulations 2009 and CQC guidance. This includes (where applicable) notifications about:

• Serious injuries/events, abuse allegations, or events that significantly affect people using the service.
• Safeguarding incidents that meet notifiable thresholds.
• Other notifiable incidents/changes set out in the statutory notification regulations and CQC guidance.

Process:

• The out of hours manager must ensure the incident is recorded immediately and flagged as “Potential CQC notification”.
• The registered manager (or nominated deputy) is responsible for submitting the CQC notification and ensuring any required parallel notifications/referrals are made (e.g., safeguarding to the Local Authority, notifications to commissioners where relevant).
• If the incident occurs on a weekend/bank holiday, the on-call escalation must ensure the registered manager (or deputy) is informed without delay so that statutory deadlines can be met.
• Evidence of submission (reference number/date/time) must be saved in the incident record and reviewed as part of governance.

Procedure for Staff

When to Use the Out of Hours Service

Staff must use the out of hours service for:

• Medical emergencies or urgent health concerns requiring immediate assessment or action.
• Any safeguarding concerns, allegations, or suspicions of abuse or neglect.
• Sudden changes in a client’s condition or behaviour that pose a risk.
• Unplanned staff absences impacting client safety (e.g., last-minute sickness or no-shows).
• Medication errors or missed doses requiring urgent advice or action.
• Equipment failures that affect care delivery or safety.
• Any serious incident or near miss that could compromise client wellbeing.
• Any allegation against a staff member (including potential abuse, neglect, theft, financial abuse, harassment, or boundary concerns).

Allegations against staff (out of hours)

Where an allegation is made against a staff member, the immediate priority is to protect the client and reduce risk. The out of hours manager must:

• ensure the alleged staff member is removed from the situation (and from further visits if needed) pending management review,
• ensure the client is safe and supported (including arranging alternative staff),
• make or initiate safeguarding referrals in line with local authority processes, and
• ensure the incident is logged as a potential CQC statutory notification where relevant.

How to Contact the Out of Hours Manager

Call the out of hours number: {{org_field_out_of_hours}}

• Clearly state:
  • Your name and job role.
  • The client’s name and address (if applicable).
  • The nature of the issue and any immediate risks.
• Remain calm, factual, and provide clear information.
• Follow any instructions or guidance provided.

 

Out of Hours Manager Responsibilities

• Assess the Situation: Gather all relevant information to understand the issue.
• Access to essential information and decision-making authority
  • The out of hours manager must have access to the information needed to manage risk safely (e.g., care plans, risk assessments, MAR information where relevant, emergency contacts, and escalation contacts), while maintaining confidentiality and data protection requirements. The out of hours manager has authority to:
  • initiate escalation to emergency services and/or external professionals,
  • deploy senior staff to attend in person where needed to maintain safe delivery of care,
  • implement staffing contingency actions to protect visits and client safety, and
  • initiate immediate safeguarding protective actions in line with safeguarding procedures.
  • Where decisions fall outside the out of hours manager’s authority (e.g., high-risk safeguarding, serious incident, media/police liaison), they must escalate to the registered manager or senior on-call without delay.
• Provide Advice and Support: Offer clear guidance and reassurance to staff, ensuring that urgent needs are met promptly.
• Take Action:
  • Where appropriate, liaise with external services (e.g., 111, ambulance, emergency GP, social services).
  • If needed, arrange for a senior staff member to visit the client’s home to support care delivery.
  • Escalate to emergency services when immediate medical intervention is required.
• Record Keeping:
  • Document the details of the call, actions taken, and the outcome in the appropriate records (e.g., client care notes, incident forms).
  • Ensure that accurate, factual information is passed to the registered manager the following working day.

Follow-Up and Handover

• All out of hours contacts must be logged using our incident reporting and communication systems.
• The out of hours manager must ensure that any actions requiring further follow-up (such as medication reviews, safeguarding referrals, or staff absences) are clearly handed over to the registered manager or responsible staff member at the start of the next working day.
• The registered manager will review out of hours logs to ensure compliance, identify patterns or trends, and make improvements where needed.

Additional Staff Responsibilities

• Be familiar with this policy and attend any relevant training on out of hours procedures and incident reporting.
• Never ignore or delay escalating an issue that may compromise the safety or wellbeing of clients.
• Ensure that you understand how to access and use the out of hours number and follow all instructions given by the out of hours manager.
• Document and report any actions taken, in line with our policies on record-keeping, confidentiality, and data protection.

Safeguarding and Duty of Candour

In line with Regulation 13 (Safeguarding) and Regulation 20 (Duty of Candour), staff must:

• Immediately report any safeguarding concern to the out of hours manager and follow safeguarding procedures for urgent protection.
• Where an incident has caused or may have caused harm, ensure the principles of duty of candour are followed: prompt openness, an appropriate apology, clear explanation of known facts, and agreement of next steps with the person and/or their representative.
• Ensure the incident record clearly documents: what happened, immediate actions taken, escalation decisions, who was informed (including family/representative where appropriate), and follow-up actions.
• Where the incident meets the threshold for statutory reporting, ensure it is flagged for CQC notification and relevant safeguarding/commissioner reporting routes.

Training and Support

• All staff receive training on using the out of hours service as part of their induction and ongoing refresher training.
• Out of hours managers receive specific training in decision-making, risk assessment, and escalation procedures to ensure they are confident in managing urgent situations.
• We promote a culture of openness, where staff feel safe to raise concerns and know they will be listened to and supported.

Registered Manager’s Responsibilities

The registered manager has overall responsibility for:

• Ensuring the out of hours arrangements meet the Fundamental Standards.
• Reviewing all out of hours logs and incident reports to ensure quality, safety, and learning.
• Supporting staff to build their confidence in managing out of hours situations.
• Making improvements to policies and procedures based on feedback and lessons learned.

Governance, audit and learning from out of hours

The registered manager will ensure that out of hours performance is monitored and improved through:

• monthly review of out of hours logs for themes (staffing gaps, medication concerns, recurring risks),
• quality checks that actions were completed and recorded,
• trend analysis and learning shared with staff,
• updates to risk assessments/care plans where patterns indicate emerging risk, and
• assurance that statutory notifications and safeguarding actions were completed within required timescales.

Contact Details
For urgent out of hours support, please contact:
Out of Hours Number: {{org_field_out_of_hours}}

For routine enquiries or non-urgent matters, please contact the Registered Manager:

Registered Manager Name: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Registered Manager Email: {{org_field_registered_manager_email}}

This policy will be reviewed at least annually, after any serious out of hours incident, and whenever legislation, CQC guidance, or the CQC assessment framework changes.

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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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