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CH213-Night Shift Management Policy

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Registration Number: {{org_field_registration_no}}

Night Shift Management Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} provides safe, person-centred and high-quality care throughout the night for people living in our care home(s). Night shifts must be planned, staffed and managed with the same level of professional oversight, governance and regulatory compliance as daytime operations. This policy supports compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended), including (but not limited to) Regulation 9 (Person-centred care), Regulation 10 (Dignity and respect), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding), Regulation 14 (Nutrition and hydration), Regulation 15 (Premises and equipment), Regulation 16 (Complaints), Regulation 17 (Good governance), Regulation 18 (Staffing) and Regulation 20 (Duty of candour), and the Care Quality Commission (Registration) Regulations 2009 notification requirements.

1.1 Regulatory and CQC assessment framework alignment

{{org_field_name}} will manage and evidence night-time care in line with CQC’s assessment approach, including the five key questions (Safe, Effective, Caring, Responsive, Well-led) and the associated Quality Statements. Night shift practice, records, audits, learning from incidents and resident feedback will be structured so that we can demonstrate outcomes and evidence against the relevant Quality Statements (for example: Safe systems, pathways and transitions; Safe environments; Safe staffing; Involving people to manage risks; Learning culture; Governance; and Safe and effective staffing deployment overnight).

2. Scope

This policy applies to all staff working night duty in {{org_field_name}}’s registered care home(s), including the Nurse in Charge (where applicable), Senior Carer/Team Leader, Care Assistants, Waking Night staff, Sleep-in staff (where used), and any agency staff. It applies to all residents and covers night-time routines, monitoring/observations, clinical and medicines tasks, safeguarding, incident management, staffing deployment, handover, escalation and on-call arrangements. For the purposes of this policy, “night shift” is typically 10 pm – 7 am (or as locally defined on the rota).

3. Related Policies

4. Policy Statement and Principles

{{org_field_name}} recognises that night-time care requires sensitivity, vigilance, and consistent standards to maintain the safety, dignity, and well-being of the people we support. This policy ensures that night shifts are staffed by trained and competent personnel, appropriately monitored, and supported by robust procedures that maintain effective care delivery and meet regulatory expectations at all times.

4.1 Staffing, Deployment and Competency

Night shifts must have sufficient numbers of suitably skilled, competent and experienced staff on duty to meet residents’ assessed needs, including any 1:1 observations, moving and handling, continence support, dementia/distress behaviours, falls risk, pressure area care, end-of-life care, and clinical needs. The rota will identify the designated person in charge and clarify roles (e.g., medicines lead, fire marshal/evacuation lead, first aider, nurse-in-charge where applicable).

Staffing levels and skill mix will be set using resident dependency information and risk assessments and will be reviewed at least monthly and immediately after any significant change (new admission, deterioration, increased falls/behaviours, outbreak, or safeguarding risk).

Where staffing falls below the planned level, the person in charge must implement the night staffing contingency plan (see Section X), including calling in additional staff, escalating to the on-call manager, and applying risk-reduction measures while maintaining residents’ dignity and safety.

All night staff (including agency) must have completed induction and role-specific competencies for night duty (including fire procedures, emergency response, medicines where relevant, and safeguarding), and must not be deployed beyond their assessed competence.

4.2 Night staffing contingency plan

If a shift is short staffed or acuity increases overnight, the person in charge must:

  1. Re-allocate tasks based on risk (prioritise time-critical safety tasks: observations, pressure care, continence, falls prevention, medicines, responding to call bells).
  2. Escalate to the on-call manager immediately where safety could be impacted.
  3. Arrange additional staffing (bank/agency) in line with the escalation pathway.
  4. Document actions taken, residual risks, and any temporary control measures introduced.
  5. Consider external escalation where needed (e.g., 111/GP, District Nursing, 999, safeguarding referral) and ensure duty of candour processes are followed where an incident occurs.

4.3 Shift Planning and Handover Procedures

Effective communication is essential at shift changeover. Staff must receive a full verbal and written handover before the start of the night shift, detailing any changes to health conditions, incidents, medication updates, or emotional support needs. Handover forms must be completed and signed by both incoming and outgoing staff. The Registered Manager {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}} ensures oversight of handover quality through regular audits.

Handover must also include a night safety brief, confirming: resident observation requirements (including any 1:1), falls/bedrail/moving & handling risks, pressure area actions, infection prevention actions, any controlled drugs counts (where applicable), safeguarding concerns, and any open incidents requiring escalation, including whether a Duty of Candour process or CQC notification is required.

4.4 Night-Time Risk Assessments

Each person supported by {{org_field_name}} must have a personalised night-time risk assessment within their care plan. This includes: frequency of monitoring, falls risks, continence needs, epilepsy management, use of assistive technology (e.g. sensor mats), and any behaviours that require support. Risk assessments are reviewed at least quarterly or after any change in need. Staff are trained to respond to emergencies such as falls, breathing difficulties, or unexpected absence.

4.5 Care home environment, security and fire safety checks

The person in charge must ensure documented night checks are completed for:

Any defects must be reported immediately, actions taken to reduce risk, and escalated to maintenance/on-call as appropriate. Where a defect creates an immediate safety risk, the contingency plan must be implemented.

4.6 Consent and least restrictive night-time practice

Overnight care must be delivered in line with the resident’s consent and agreed care plan. Where restrictions are used (e.g., sensor mats, door alerts, bedrails, increased observations), these must be risk assessed, least restrictive, time-limited where possible, reviewed, and documented. Any concerns about liberty restrictions or capacity/consent must be escalated in line with the Mental Capacity Act policy and safeguarding procedures.

4.7 Medication and Clinical Tasks

Any medication administered at night must be documented clearly in the Medication Administration Record (MAR). Staff must be trained and assessed as competent before administering medication during night shifts. PRN (as-needed) medications must have clear protocols in place, and any administration must be recorded and justified. Clinical tasks such as catheter care, turning to prevent pressure ulcers, or nutritional support must be documented and reviewed regularly.

4.8 Record-Keeping and Reporting

Staff must maintain accurate and timely documentation during the night shift, including care logs, repositioning charts, fluid intake, checks, and any concerns noted. All entries must be factual, signed, and dated. Any significant events or safeguarding concerns must be reported immediately via our on-call system and documented using the incident reporting process outlined in CH24.

In addition to internal reporting, the person in charge must ensure that CQC notifications are made for notifiable events/incidents in line with the Care Quality Commission (Registration) Regulations 2009, including (where applicable) death of a person using the service, serious injury, allegations of abuse, police involvement, events that stop the service running safely, and other incidents that must be notified. Where the incident occurs overnight, the night shift must ensure the notification is escalated for completion by the next working day (or sooner where required) and that the handover clearly identifies that a CQC notification is required.

4.9 Duty of Candour

Where a notifiable safety incident occurs, staff must ensure immediate safety actions are taken and must escalate to the on-call manager/Registered Manager without delay so that the organisation can meet the Duty of Candour requirements. This includes: prompt initial notification to the resident and/or their representative, an apology, an explanation of known facts, ongoing updates, written follow-up within required timescales, and accurate contemporaneous records of all communication and learning actions.

4.10 Lone Working and Staff Safety

Night staff working alone are supported by the Lone Working Policy (CH23). Measures in place include:

Staff must not place themselves at risk and must escalate concerns about unsafe environments or aggressive behaviour immediately.

4.11 Sleep-In Arrangements

Sleep-in duties may only be used where resident risk assessment and dependency data confirm that a waking night presence is not required for safety. A sleep-in worker must have a suitable sleeping area and must be able to respond immediately when called. Sleep-in time must not be relied upon as the sole measure to meet residents’ assessed night-time needs. All call-outs/interventions must be recorded, including time, reason, action taken and any escalation.

4.12 On-Call and Emergency Response

A designated on-call manager is available during all night hours to provide support, advice, and decision-making assistance. Staff must be informed of the on-call contact details and escalation process. In an emergency, staff must prioritise the safety of the individual, contact emergency services where necessary, and inform on-call immediately.

4.13 Staff Wellbeing and Monitoring

Fatigue can affect judgement and performance during night shifts. {{org_field_name}} promotes the health and wellbeing of night staff by:

4.14 Quality Assurance and Auditing

Night shift records, handover forms, and care logs are audited weekly to ensure completeness and quality. Observational spot checks are conducted to ensure compliance with care standards. Feedback from individuals supported at night and their families is actively encouraged to identify improvements. All findings are reviewed by the Registered Manager and actions taken where necessary.

5. Policy Review

This policy will be reviewed annually or sooner if there are changes in legislation, guidance, or operational needs.

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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.

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