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CH23-Lone Working and Staff Safety Policy

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Lone Working and Staff Safety Policy

1. Purpose and Scope

This policy outlines {{org_field_name}}’s commitment to protecting the health, safety and welfare of staff who may work alone within our residential or nursing care home facility. It is designed in the voice of a Care Quality Commission (CQC) inspector, emphasizing compliance with current CQC standards and best practices. The policy applies only to staff working on-site in our care home (including care staff, nurses, ancillary and support staff) and not to domiciliary or community care settings. While lone working is often associated with home care, care home employees can also find themselves working alone – for example, during night shifts or in isolated parts of the building. This policy ensures that we meet our legal obligations under health and safety law and aligns with CQC’s fundamental standards for safe, well-led care services.

2. Definitions – Lone Working in a Care Home

Lone working refers to any situation where a staff member performs their duties without immediate presence or close supervision of colleagues. In simple terms, a lone worker is someone who “works on their own, with no direct or close supervision”. Within a care home, this can occur when a person is the sole staff member on duty or when they are physically isolated from co-workers. Examples include: a single care assistant on an overnight shift; a nurse attending to residents in one wing while colleagues are elsewhere; a maintenance or cleaning staff member working in a remote area of the facility; or any staff member temporarily alone with a resident. During these periods, the lone worker does not have another staff member immediately available to assist or summon, which may increase certain risks.

It is important to note that working alone is not inherently unsafe, but lone workers can be more vulnerable because there is no one to help if something goes wrong. For the purposes of this policy, “staff” includes all employees, agency workers, or contractors working on our premises. “Residents with challenging behaviours” refers to service users who, due to cognitive impairment, mental health, or other factors, may exhibit aggression, violence, or unpredictable behavior that could pose a risk to themselves or others. Understanding these definitions ensures clarity about when this policy is to be followed.

3. Risk Assessment Procedures for Lone Working

Risk assessment is the cornerstone of preventing harm in lone working situations. In accordance with the Management of Health and Safety at Work Regulations 1999, {{org_field_name}} will identify and assess all potential hazards faced by lone workers and take steps to mitigate them. We follow the five-step risk assessment process recommended by the Health and Safety Executive (HSE):

Identify Hazards: Recognize anything with the potential to cause harm to a lone worker. This includes environmental hazards (e.g. poor lighting, unlocked access at night), work-related hazards (like a task that requires two people), and person-specific hazards (for example, a resident known to be aggressive).

Determine Who May Be Harmed and How: Consider which staff might be exposed to each hazard and in what way. For instance, night staff face risk of violence or intruders, housekeeping staff working in isolated areas might be vulnerable to accidents without immediate help, and caregivers alone with a resident could face aggression.

Evaluate Risks and Implement Controls

For each identified hazard, {{org_field_name}} will carry out a suitable and sufficient assessment of the risk and will identify and implement appropriate preventive and protective measures. Risks arising from lone working will be eliminated where reasonably practicable and, where they cannot be eliminated, controlled so far as is reasonably practicable in accordance with the Health and Safety at Work etc. Act 1974 and the Management of Health and Safety at Work Regulations 1999.

The assessment must consider whether the work can safely be carried out by one person. Lone working will not be permitted where the risk assessment identifies that the task, resident’s assessed needs, environment, equipment, emergency arrangements or other circumstances require the presence of more than one suitably trained and competent member of staff.

Control measures will be proportionate to the identified risk and may include:

The risk assessment must identify the limits of what may safely be undertaken by a lone worker and the circumstances in which the worker must stop the activity, withdraw to a place of safety or summon additional assistance. Staff must not be expected to continue an activity where the controls identified by the risk assessment are unavailable or ineffective.

Record Findings and Develop Action Plans: The risk assessment findings and the measures to mitigate risk will be documented. For each identified risk, the record will note what control measures are in place (e.g. “Resident X – risk of aggression: staff must use two-person care or carry alarm, see care plan”). This written record ensures accountability and makes the information accessible to all relevant personnel.

Review and Update: The registered manager will review lone working risk assessments at least annually and whenever there is reason to believe circumstances have changed. Any incident involving a lone worker or any significant change (such as new residents with challenging behavior, new equipment, or different building layout) will trigger an earlier review. We are committed to updating our strategies if an assessment is no longer valid or if better controls are identified.

Specific considerations are made for violence and aggression risks. The HSE defines workplace violence as “any incident in which a person is abused, threatened or assaulted in circumstances relating to their work,” including verbal threats. Within a care home, this could involve a resident or visitor being threatening toward staff. Our risk assessment will flag any residents with known history or triggers for violence. If a particular resident or situation is assessed as too high-risk for a lone worker, the care plan will specify that two staff must be present or alternative arrangements made to protect staff. We also assess the work environment (e.g. isolated laundry rooms, parking lots at night) and worker factors (like whether a staff member has a medical condition that could suddenly incapacitate them – in such cases we adjust work assignments to avoid that person working alone, or ensure additional safeguards).

By diligently assessing these risks, {{org_field_name}} ensures that preventative and protective measures for lone workers are in place and effective before an individual works alone. Risk assessments are living documents – they will be communicated to staff and revisited whenever needed to maintain a safe working environment.

4. Roles and Responsibilities

Safety in lone working is a shared responsibility. This section outlines the duties of the care provider’s management and staff to implement and uphold this policy.

Registered Provider and Registered Manager

The Registered Manager (and the care home’s provider organization) holds primary responsibility for establishing a safe system of work for lone workers. In the spirit of CQC’s expectations for good governance and safe care, the manager will:

Develop and Enforce Policy: Ensure this Lone Working and Staff Safety Policy is in place, up to date, and reflects current legislation and CQC guidance. The manager must lead by example in promoting a culture that prioritizes safety for both residents and staff.

Staffing Levels

The Registered Provider and Registered Manager must ensure that sufficient numbers of suitably qualified, competent, skilled and experienced staff are deployed at all times to meet the assessed needs of people using the service and to enable the service to comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staffing arrangements, including night staffing and any proposed lone-working arrangement, must be determined through an assessment of the needs, dependency, risks and required care of people using the service together with the layout of the premises, staff competence, moving and handling requirements, foreseeable emergencies, safeguarding risks and the home’s fire risk assessment and emergency arrangements.

Lone working must not be introduced or continued solely because of staff shortages, sickness, vacancies, financial considerations or difficulty obtaining cover.

Where a person’s care plan, risk assessment, moving and handling assessment, behaviour support plan, emergency arrangement or other assessed need requires two or more members of staff, sufficient suitably trained and competent staff must be available to meet that requirement.

The Registered Manager must review staffing arrangements whenever there is a material change in people’s needs or risks, occupancy, the environment, the skills or experience of available staff, fire or emergency arrangements, or following an incident or near miss that indicates that existing staffing arrangements may no longer be safe.

If safe staffing cannot be maintained, the Registered Manager or appropriate senior person must take immediate action to protect people using the service and staff, including arranging additional competent staff and escalating the matter in accordance with the provider’s contingency and business continuity arrangements.

Competence and Supervision: Only allow staff to work alone if they are deemed competent and confident to do so. New or inexperienced employees will be supervised and will not be placed in lone-working situations until they have demonstrated the required levels of competence to carry out their duties unsupervised. The manager ensures all lone workers are properly trained (see Training section) and provides ongoing supervision through regular one-to-one check-ins or observations. Where appropriate, especially for high-risk situations or new staff, the manager (or a delegated senior person) should periodically visit or observe the lone worker to ensure procedures are followed.

Risk Assessments and Planning: Conduct and approve all lone working risk assessments, as detailed above. The manager must ensure that for each lone-working scenario, a clear plan and control measures are in place. This includes arranging for any personal safety devices, establishing check-in routines, and documenting emergency procedures. The manager will involve employees in this process, considering their input on what might make them feel safer.

Provision of Equipment and Resources: Supply necessary safety equipment (e.g. personal alarms, mobile phone or two-way radio, torches for night staff, first aid kits) and ensure that security measures (like door locks, lighting, CCTV where used) are functioning. Technological solutions for communication and alarm are provided as needed so that every lone worker has an effective way to call for help.

On-call Support: Arrange an on-call system so that lone workers (particularly at night) have a designated person to contact for urgent assistance or advice. The on-call person (which could be the manager, senior staff, or on-call supervisor) must be available and able to respond or attend the site if an emergency arises.

Emergency Procedures: Establish clear emergency protocols for likely scenarios – such as fire evacuation with minimal staff, medical emergencies when alone, or responding to a violent incident. The manager should ensure these procedures are drilled (practiced) or at least reviewed with staff so that lone workers know exactly what to do. In line with CQC guidance, there should be procedures to ensure sufficient additional help can be summoned in an emergency, so both the emergency and routine care are covered.

Incident Response and Investigation: If a safety incident or “near miss” occurs while someone is working alone, the manager must be notified (directly or via the on-call supervisor) as soon as possible. The manager will respond immediately to support the staff member (ensuring they get medical attention or relief from duty if needed) and to address any ongoing risk. Afterwards, the manager will investigate the incident, document it in the incident log, and report to external authorities if required (including RIDDOR reporting to the HSE in the event of certain injuries or incidents). Lessons learned will be used to improve this policy or risk assessments. The manager is responsible for providing debriefings and follow-up support to the affected staff (see Post-Incident Support).

Policy Review: Review this policy at least annually, and sooner if regulations change or if a serious incident suggests that policy or practices should be updated. Consultation with staff and safety representatives should be part of the review to ensure the policy remains effective and realistic.

Overall, the Registered Manager must foster an environment where lone workers feel safe, supported, and able to raise concerns. The manager’s leadership in health and safety should ensure that “all reasonable steps” are taken to protect staff who work alone.

5. Care Staff and All Employees

Every staff member has a personal responsibility to follow safety procedures and to take reasonable care of themselves and others. Employees expected to work alone in the care home (including care assistants, nurses, cleaners, kitchen staff, maintenance personnel, or any other role) must:

Follow Procedures and Precautions: Adhere strictly to the lone working procedures outlined in this policy and in any site-specific instructions or risk assessment. For example, if the procedure requires checking in with a colleague or manager at set times, the staff member must do so reliably. If issued a personal alarm or phone, they must carry it at all times during their lone work and ensure it is charged/functional.

Use Equipment Properly: Make use of provided safety devices (panic alarms, communication devices, etc.) according to training. Do not tamper with or disable safety equipment. If a device or alarm is not working, report it immediately so it can be fixed or replaced.

Conduct Dynamic Risk Assessments: Remain vigilant and assess situations as they arise. Staff should continually be aware of their environment and the behavior of residents or visitors. If at any point a lone worker feels unsafe or identifies a new hazard (e.g. discovering an unsecured door, or a normally calm resident becoming agitated), they should alter their plan, seek assistance, or remove themselves from the situation as appropriate. Employees are empowered to stop work and call for help if a risk emerges that they cannot manage alone.

Communication: Keep in touch as per the established methods. Carry the phone/radio, respond to check-in calls or messages from supervisors, and promptly report any incident or suspicious circumstance. If the lone worker is going on a break or stepping away from their normal area, they should notify a colleague or on-call manager so that their whereabouts remain known. We emphasize a “no blame” culture for calling for assistance – staff should never feel they have to “cope alone” with a risky situation.

Not Take Unwarranted Risks: Avoid any work task that has been designated as unsafe for one person. For example, do not attempt to physically restrain a violent resident – instead use de-escalation techniques and retreat to safety, triggering the alarm for backup if needed. Do not lift or move a resident alone if that resident’s care plan calls for two staff during transfers. If uncertain whether a task is safe to do alone, the staff member should pause and consult a supervisor.

Report Hazards and Incidents: Immediately report any accidents, near misses, threats, or concerns experienced while working alone, no matter how minor they may seem. This includes reporting if a resident threatens them, if they felt unsafe at any point, or if an injury was narrowly avoided. By reporting, staff enable the manager to take action to improve safety measures. All incidents must be logged according to the home’s incident reporting procedure.

Attend Training and Meetings: Participate in all training sessions related to lone working, personal safety, conflict management, first aid, etc., as provided by the employer. Similarly, attend safety briefings or debriefings (for example, after an incident or during staff meetings where safety is discussed). Applying the training in day-to-day work is expected. If any staff member feels they need additional training or guidance before working alone, they should inform the manager.

Self-Care and Fitness for Duty: Be mindful of their own physical and mental well-being. If an employee knows of any health condition or limitation that might affect their ability to work alone safely (for instance, a medical condition that could cause sudden illness, or extreme anxiety about lone working), they must inform the manager. The home will follow HSE guidance to assess if any adjustments or medical advice are needed for that staff member. Additionally, staff should ensure they are not overtired or impaired at work, as this could increase the risks of lone working. Use allocated rest breaks and request support if feeling overwhelmed or stressed.

Team Support: Even when working alone, staff are part of a team. Colleagues should support each other by checking on lone workers when possible (a simple phone call to the night staff to ask “Are you okay?” can make a difference). If an employee knows a co-worker is alone in a challenging situation, they should be ready to assist or alert others if needed, as long as it does not compromise resident care or their own safety.

By accepting these responsibilities, staff help maintain a safe working environment. Ultimately, no job should be done in a way that compromises personal safety – all employees have the right to refuse unsafe work and to be provided with the means to work safely, even when alone.

6. Others (Contractors, Agency Staff, etc.)

Any contractors or agency personnel working on the premises (for example, temporary nurses, maintenance contractors after hours, security personnel, delivery drivers on-site at night) are also covered by this policy when they work unaccompanied. Management will brief all external or temporary workers on relevant lone working procedures. These individuals are expected to follow the same precautions as our employees, including signing in/out of the building so we are aware of their presence and location. Contractors must have their own lone working risk assessments as required, but {{org_field_name}} will coordinate to ensure their safety is managed while on our site.

Lone Working Procedures and Safe Practices

This section describes the procedures staff should follow and specific precautions in common lone working scenarios within our care home. By adhering to these practices, we reduce the risks associated with working alone.

1. Working During Night Shifts and Out-of-Hours

Reduced staffing during the night or at other out-of-hours periods must not result in unsafe lone working. There is no automatic entitlement to operate a care home with one member of staff on duty. Before any member of staff works alone, the Registered Manager must be satisfied through documented risk assessment and staffing assessment that the arrangement is safe, that people’s assessed care and support needs can be met and that the service can respond effectively to foreseeable emergencies.

Staffing and Authorisation

Any lone-working arrangement during a night shift or other out-of-hours period must be expressly authorised through the home’s staffing and lone-working risk assessment.

The assessment must consider, as a minimum:

Where these requirements cannot be safely met by one member of staff, lone working must not take place and additional suitably trained and competent staff must be deployed.

Handover and Information

At the start of the shift, staff must receive an appropriate handover containing all information necessary to provide safe care. This must include any change in a person’s condition, behaviour, mobility, falls risk, moving and handling needs, observation requirements, medical needs, evacuation arrangements or other factor that may affect safe staffing or lone working.

Any fault affecting call bells, alarms, doors, lighting, communication equipment, fire-safety systems or other safety equipment must be reported immediately. Where the fault makes the approved lone-working arrangement unsafe, the arrangement must not continue until adequate alternative controls or additional staffing have been put in place.

Security of the Premises

Staff must follow the home’s security procedures, including arrangements for external doors, windows, access control, lighting and authorised visitors.

Staff working alone must not confront a suspected intruder or place themselves at avoidable risk. Where there is an immediate threat or suspected criminal activity, staff must withdraw to a place of safety where possible and contact the police using 999 where an emergency response is required.

Care Requiring More Than One Member of Staff

A member of staff working alone must not undertake any intervention identified by an individual’s care plan or risk assessment as requiring two or more members of staff.

This includes moving and handling procedures where two staff are specified, and any other care or intervention that the person’s risk assessment states cannot safely be undertaken by one person.

The absence of sufficient staff does not authorise a member of staff to disregard the person’s care plan, moving and handling assessment or risk assessment.

Where required care cannot safely be provided because the necessary staff are unavailable, the member of staff must seek immediate assistance and escalate the matter to the on-call manager or other designated senior person.

Communication and Monitoring

Any authorised lone worker must have a reliable means of summoning assistance and must participate in the monitoring arrangements specified by the lone-working risk assessment.

The arrangements must include:

Communication and alarm arrangements must be tested at appropriate intervals and following any relevant change or fault.

Fire and Other Emergencies

Night-time staffing arrangements must be consistent with the home’s current fire risk assessment, emergency plan and the evacuation needs of people using the service.

The provider must not rely on an informal arrangement with neighbours, members of the public or other persons who are not part of an established and suitable emergency arrangement as a substitute for sufficient trained staff.

Staff must know:

No policy statement should assume that the fire and rescue service will be contacted automatically unless the home’s specific fire-alarm arrangements have been verified as providing that facility.

Where the fire risk assessment or emergency evacuation plan establishes that more than one member of staff is necessary to implement the required evacuation strategy safely, the home must deploy that number of suitably trained staff.

Medical Emergencies

Where a person using the service experiences a medical emergency, staff must summon appropriate emergency assistance without avoidable delay and follow the person’s emergency care information and the home’s emergency procedures.

A lone worker must not attempt an unsafe manual lift following a fall. The person must be assessed and kept safe and comfortable while appropriate assistance is obtained in accordance with the home’s falls and emergency procedures.

Staff Illness or Incapacity

A lone worker who becomes unwell or is unable to continue their duties safely must contact the designated manager or on-call person immediately. Appropriate replacement cover must be arranged where necessary to maintain the safety of people using the service.

The provider’s monitoring arrangements must also address circumstances in which a lone worker becomes incapacitated and cannot themselves call for assistance.

End-of-Shift Handover

At the end of the shift, the member of staff must provide an appropriate handover and report all incidents, near misses, hazards, equipment failures and other concerns arising during the shift.

Where a formal lone-worker monitoring system is used, the worker must also confirm that the lone-working period has ended so that any outstanding alert or welfare-check process can be closed safely.

2. Working in Isolated Areas of the Facility

Lone working can also occur during the day or evening in less visible or isolated parts of the care home. This might include a staff member working alone in the laundry room, a maintenance technician servicing equipment in the attic or boiler room, a carer accompanying a resident to a remote part of the gardens, or even a nurse alone in a separate unit or floor. To ensure safety in these situations, the following procedures apply:

Notification of Location: Staff who are going to be working in an area of the building away from others should inform a colleague or supervisor of their location and expected duration. For example, a maintenance staff going to fix something in the basement should radio or tell reception, “I’ll be in the boiler room for the next hour.” This way, others are aware of where the person is if they don’t return as expected.

Use of Communication Devices: Employees must carry a means of communication (cordless phone, walkie-talkie, or mobile phone) when in isolated service areas. The device should have signals in those areas – if there are known “dead zones” for signal (e.g. some boiler rooms may block phone signals), the risk assessment will address how to manage that, such as checking in more frequently or using a different communication method. If a radio or DECT phone is provided, ensure it’s on and set to the correct channel.

Buddy System for High-Risk Tasks: If an isolated task carries particular risk (for instance, heavy lifting, climbing a ladder, or using potentially hazardous equipment), staff should not undertake it completely alone. The manager will arrange for a “buddy” to either assist or at least be on standby nearby. For example, if a housekeeper must move heavy furniture to clean, another staff member should be present to help or the task should be scheduled when more staff are available. Where that’s not possible, at minimum another staff should know to check on the person after a short interval. Certain tasks (like entering confined spaces or significant maintenance work) are outright prohibited for solo work per health and safety regulations – we will always adhere to any such requirements.

Awareness of Exits and Alarm Points: When working in secluded areas, employees should be aware of their nearest exit routes and alarm call points. For example, if cleaning a far end of a corridor, note the fire exit location; if in a plant room, have a clear path out. If an area is too enclosed or presents a security concern (for example, a windowless room with only one entry), consider propping the door open if safe to do so (to avoid being trapped) or have another person periodically calling in. In any alarming situation (equipment accident, feeling threatened by someone entering the area, etc.), staff should not hesitate to leave the area and seek help.

Personal Safety Practices: Even in the daytime, isolated workers should secure the area they are in if possible (e.g., if working alone in a secure medication room, keep it locked to prevent unauthorized entry by others that might pose a threat). They should also carry any personal alarm device provided. For instance, care staff often have wearable alarm pendants; these must be worn even when doing tasks like taking out trash to an outdoor bin or tending to a resident in a distant cottage on the premises. If a personal alarm is activated, it will alert colleagues at the main site who can respond. Management ensures that any alarm system used can effectively cover the remote areas, or else alternative arrangements (like a cell phone call) are set.

Time Limits and Check-ins: Working in isolation should ideally have defined time limits. If someone does not report back or finish within the expected time, a colleague will check on them. For example, if the laundry worker normally checks back every 30 minutes and fails to do so, staff will attempt to contact them or go to the laundry room to ensure they are safe. This regular contact approach is in line with guidance to have “pre-agreed intervals of regular contact” with lone workers. Employees themselves should also be proactive: if their task is taking longer than anticipated, they should update their contact person that they are still okay but need more time.

Special Consideration: Solo Outings or External Areas: If a staff member leaves the main building with a resident (say, accompanying a single resident on a walk in the garden or to a medical appointment), it becomes a lone working scenario for that staff. In such cases, portable communication (mobile phone) is mandatory, and the staff should have access to emergency contacts. A risk assessment will be done for any regular practice of solo outings – for example, if one staff takes a resident with learning disabilities to the park regularly, we will assess any known risks (does the resident have a history of aggression or wandering off that would make one-to-one support unsafe?). If risks are high, two staff may be required for outings. If it’s assessed as safe, then the lone staff must still follow all other safety steps (carry phone, have an emergency plan such as contacting the home or emergency services if an incident occurs externally).

Environmental Hazards: In isolated work areas, things like poor ventilation, high noise (machinery), or chemical use (cleaning chemicals) can pose risks. Our risk assessments cover these, and staff must use any protective equipment and follow protocols (e.g., do not climb on chairs or makeshift ladders – use proper step ladders; wear alarm in case of a fall). If any area is deemed too dangerous for one person (for example, a roof space with a risk of falls), the manager will ensure a two-person team or professional contractors handle it.

By following these precautions, staff can safely carry out duties even when they are physically apart from others on-site. Communication and awareness are key: everyone in the facility should know when and where colleagues might be working alone so that we can “keep eyes out” for each other’s safety.

3. Working with Residents Who Have Challenging Behaviours

Caring for residents with dementia, mental health conditions, or other complex needs can sometimes expose staff to challenging or aggressive behaviors. When a staff member is alone with such a resident, the situation warrants particular care. Our policy to safeguard both staff and residents includes:

Individual Risk Assessments and Care Plans: Each resident who has a known history or potential for aggression, violence, or severe uncooperative behavior will have this risk noted in their care plan. The care plan will specify any triggers to avoid (for example, particular approaches that might upset them) and strategies for de-escalation. Crucially, the plan will indicate whether two staff members are required for certain interactions. For instance, if a resident tends to strike out during personal care, the plan may require two carers present in the room for intimate care tasks. Lone workers must adhere to these requirements – do not attempt a two-person assist or intervention alone with a high-risk resident. The manager is responsible for scheduling staffing such that these care plan directives are followed.

Training in De-escalation: All care staff receive training in how to respond to agitation or aggression (e.g., dementia care techniques, de-escalation and distraction, maintaining safe distance, etc.). When working alone with a potentially challenging resident, staff should use these techniques early at signs of distress. The goal is to prevent escalation. Staff are trained to recognize situations where they feel at risk and to use conflict resolution or exit strategies. For example, if a resident starts to become aggressive, the lone worker should prioritize their own safety: this might mean verbally calming the person while backing away toward an exit, or temporarily leaving the room to give the resident space. It is acceptable for staff to withdraw from a violent situation – personal safety comes first, then seek help.

Use of Personal Alarms: When alone with a resident who has challenging behavior, staff must have their alarm device on their person (worn in a way that they can activate it quickly, such as on a belt clip or pendant). In the event that a resident’s behavior becomes immediately dangerous (for example, a staff is cornered or physically assaulted), pressing the alarm will alert colleagues (or an external monitoring service if configured) to send assistance. Where available, panic alarms or emergency call buttons in the room should also be identified in advance. If the situation allows, the staff member can use coded language over the radio/phone to summon help without escalating the resident (for instance, saying a pre-arranged phrase that signals distress to other staff).

Avoidance of High-Risk Triggers When Alone: Staff should, where possible, schedule activities with a challenging resident at times when another staff is nearby or on the premises. If a lone worker is on duty and a resident prone to aggression has a need, the staff should evaluate if it can be safely handled alone. For example, giving routine medication through a hatch or at arm’s length if a resident is in a secluded mood might be safer than entering their personal space alone. If there is any doubt, the staff should call for back-up or wait for assistance (even if that means the resident’s care is slightly delayed) – this should be communicated to management, who will support the decision to prioritize safety.

Emergency Protocol if Attacked or Threatened: In the unfortunate event a lone staff member is attacked or believes they are in imminent danger from a resident, the protocol is: remove yourself from danger if at all possible, use your alarm or phone to call for immediate help, and as soon as safe, call emergency services (such as police) if the threat is severe. The home will treat any such incident with utmost seriousness – violent incidents are not “part of the job” and will be met with a response to protect staff. If a resident cannot be safely managed even with two staff, the provider will seek specialist support or consider alternative placement for that resident, as the safety of both staff and other residents is paramount.

Reporting and Post-Incident Review

Any incident involving violence, aggression, threats or abuse towards a member of staff must be reported and recorded in accordance with the provider’s incident reporting and health and safety procedures. The incident must be reviewed to identify contributing factors, whether existing control measures were adequate and whether changes are required to the person’s care plan, risk assessment, behaviour support arrangements, staffing arrangements or lone-working controls.

Work-related violence includes circumstances in which a worker is abused, threatened or assaulted in connection with their work. Staff must therefore report relevant verbal threats as well as physical assaults.

Where an incident also gives rise to a concern that a person using the service has experienced, is experiencing or is at risk of abuse or improper treatment, the provider must follow its safeguarding procedures and Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Regulation 13 protects people using the service from abuse and improper treatment. The employer’s duties to protect staff from work-related violence arise principally under health and safety legislation. The provider’s governance arrangements must also identify, monitor and mitigate risks to people using the service and others who may be at risk from the carrying on of the regulated activity.

Following an incident, the provider must ensure that relevant learning is identified, action is implemented and the effectiveness of the revised controls is reviewed.

We acknowledge the dedication it takes to care for individuals with challenging behaviors and affirm that no staff member should ever feel alone or helpless in such situations. This policy ensures there are always systems in place – be it another person on call, an alarm, or a procedure – to back up a lone worker when they are supporting some of our most vulnerable (and sometimes unpredictable) residents.

7. Communication, Supervision, and Emergency Response

Effective communication and oversight are essential to keep lone workers safe. {{org_field_name}} employs multiple methods to ensure lone staff stay connected and are supported, especially in emergencies.

Regular Contact and Monitoring: We maintain a reliable system of keeping in touch with lone workers. As described in earlier sections, this may include scheduled phone calls, radio check-ins, or electronic check-in systems at set intervals. For example, a lone worker might have to send a text to their line manager every two hours, or use an app to check-in when they have completed certain rounds. The frequency of contact is determined by risk level – higher risk situations warrant more frequent checks. All lone workers must understand these monitoring procedures and comply with them. If a lone worker fails to check in as expected, the protocol is for the supervisor or on-call manager to promptly follow up (attempt contact via phone, then escalate to physically checking or calling emergency services if needed). We also utilize electronic systems (where available) that can log when a lone worker has not “checked out” after a shift, alerting managers to verify their safety.

Communication Tools: The home provides or requires appropriate communication devices for lone working periods. Staff may be equipped with mobile phones, two-way radios, pagers, or specialized lone worker devices that have emergency call features. Even a simple solution like a two-way radio or phone can be lifesaving, so long as it is carried and functional. In some cases, we use personal alarm systems that are monitored: for instance, a pendant alarm that, when activated, notifies a monitoring center or on-site alert panel with the staff’s identity and location. We ensure that “there is always a method of communication with lone workers in place – even if the staff member is working at night”. Staff are trained in using these devices (e.g., how to trigger the alarm, what button to press for man-down alert, etc.), and the equipment is tested regularly. We also ensure coverage: if a staff’s mobile phone is the primary device, we check that network reception is adequate in all working areas, or provide alternatives if not.

Supervision and Spot-Checks: Although lone workers operate without colleagues beside them, they are not without supervision. The level of supervision is based on risk assessments – higher risk or inexperienced staff get more frequent supervisory oversight. Supervisors or managers will occasionally make unannounced visits or calls during a lone work shift to observe or verify that all is well (for example, the duty manager might drop in during a night shift at 10 p.m. for a round). New employees or those new to a task will initially have direct supervision until they demonstrate they can work safely alone. Regular supervision meetings (one-to-one sessions) are also used to discuss any issues the staff member has regarding lone working, reinforcing that management is actively involved in their safety.

Emergency Response Planning

{{org_field_name}} will maintain emergency procedures that take account of any period during which a member of staff may be working alone. Lone-working arrangements must not compromise the provider’s ability to protect people using the service or to respond effectively to foreseeable emergencies.

Medical Emergency Involving a Person Using the Service

Where a person using the service experiences a medical emergency, the member of staff must immediately assess the situation within the limits of their training and competence, summon emergency medical assistance where required and follow the person’s emergency care information and the home’s relevant emergency procedure.

A member of staff must not delay contacting 999 where emergency assistance is required because they are attempting to manage the situation alone.

The staff member must also summon appropriate on-site or on-call assistance in accordance with the home’s arrangements. Arrangements must be in place to ensure the safety and continuity of care of other people using the service while the emergency is being managed.

Medical Emergency or Accident Involving a Member of Staff

Lone workers must have access to a reliable means of summoning assistance.

Where the member of staff becomes ill or injured and is able to do so, they must contact the appropriate emergency service and the designated manager or on-call person as required.

The home’s lone-worker monitoring arrangements must include a process for identifying a missed contact or other indication that the member of staff may have become incapacitated. The procedure must specify who will respond, how quickly the matter will be escalated and when emergency services must be contacted.

Where the member of staff can no longer safely continue their duties, suitable replacement staffing must be arranged without avoidable delay.

Violence, Aggression or Security Threat

A member of staff who is threatened with violence or aggression must prioritise immediate safety, use trained de-escalation techniques where appropriate and safe, withdraw from the situation where necessary and summon assistance.

A lone worker must not be required to confront an intruder or suspected intruder. Where there is an immediate threat to life or safety, the police must be contacted using 999.

Following any violent or threatening incident, the incident must be reported, appropriate support provided and relevant individual and environmental risk assessments reviewed.

Fire

The home’s staffing arrangements at all times, including overnight and other periods of reduced staffing, must be compatible with the current fire risk assessment, emergency plan and the evacuation needs of people using the service.

Staff must follow the home’s approved evacuation strategy and must receive appropriate fire-safety information, instruction and training.

The Registered Provider and Registered Manager must ensure that sufficient suitably trained staff are available to implement the home’s fire emergency plan safely. An informal expectation that neighbours, visitors or members of the public will assist in evacuation must not be used as a substitute for adequate staffing or formal emergency arrangements.

Staff must know how to raise the alarm and how the fire and rescue service will be contacted. The policy must not assume that activation of the fire alarm automatically contacts the fire and rescue service unless the provider has confirmed that the specific alarm and monitoring arrangement provides that function.

Utility Failure, Flood or Other Environmental Emergency

The member of staff must follow the home’s emergency and business continuity procedures for failures of electricity, gas, water, heating, communications or other essential systems, flooding, structural damage and other environmental emergencies.

The Registered Manager or designated on-call person must be contacted promptly where the event may affect safe care or the safe operation of the premises.

Where an incident threatens the provider’s ability to continue the regulated activity safely, the provider must consider and make any statutory notification required by the Care Quality Commission (Registration) Regulations 2009.

Medical Emergency (Resident): If a lone worker faces a resident medical emergency (e.g., cardiac arrest at night with one carer), they should immediately call emergency services (999) first, then use the phone or alarm to alert the on-call nurse/manager or any nearby staff. Staff are trained not to delay calling an ambulance under the false assumption they must handle it alone – help must be summoned right away. A grab file with residents’ key medical info is accessible to give to paramedics. If multiple residents are affected (e.g., a fire or gas leak), the lone worker triggers the alarm and follows the evacuation plan – our fire alarm systems and procedures account for low staffing scenarios by immediately alerting the fire brigade and designated responders.

Medical Emergency or Accident (Staff): If the lone staff member themselves becomes ill or injured and is able, they should call for help via phone or alarm. If they are unable to do so (e.g., unconscious), our monitoring procedures (missed check-in, or alarm devices with inactivity sensors) will serve to alert others. We have instructed all lone workers to carry their mobile phone on their person, so they can dial emergency services if, say, they fell and couldn’t reach the fixed alarm. The on-call support will also respond and ensure an ambulance is called if a lone worker cannot continue their duties due to an injury or collapse.

Aggression or Security Threat: In case of personal threat (violence from a resident or intruder), the staff is instructed to remove themselves to a safe area and then call for help. If an intruder is suspected on the premises, the lone worker should not confront them; they should secure themselves (e.g., lock the office door) and call the police immediately, then the on-call manager. The home’s security measures (locks, alarms, CCTV) are designed to reduce this risk, but we have clear guidance: personal safety first, property second – do not put yourself in harm’s way to protect belongings or even residents’ property. For violent residents, as noted, use alarms and if necessary the police can be called if a resident poses an immediate serious threat that cannot be managed.

Fire or Environmental Emergency: Lone workers are trained in fire safety and drills. If a fire alarm sounds and one staff is on duty, they must begin evacuation as per the fire plan, which typically is a phased evacuation or defend-in-place until firefighters arrive, depending on the building’s design and residents’ needs. Our staffing arrangements for nights take into account fire response – for example, we may have an arrangement with a nearby on-call staff or a neighbor to assist if a fire alarm goes off at night and only one worker is present, recognizing the challenge of evacuating multiple residents alone. In a less acute scenario like power failure or flood, the lone worker contacts the on-call manager who may come in or call maintenance contractors. Emergency contact numbers for utility services are available.

Missing Check-in Protocol: If a lone worker fails to make a scheduled contact and cannot be reached, the on-call manager will treat this with urgency. Initially, repeated communication attempts (calls, texts) will be made. If no response within a very short window and the situation is abnormal (e.g., the staff always answers), the on-call person or another designated responder will physically go to the site to check on the staff. They may also contact emergency services for a welfare check if distance or other factors prevent immediate attendance. This protocol ensures that even if a lone worker is incapacitated and silent, someone will come looking in a timely manner.

Documentation and Instruction: All lone workers are provided with an Emergency Contacts Card or Sheet listing key phone numbers (on-call manager, maintenance, local police station, etc.) and summarizing what to do in critical events. This serves as a quick reference during an emergency. Additionally, the care home’s Emergency Plan (covering fire, flood, etc.) includes specific instructions acknowledging if only one staff member is present – these instructions are reviewed in training and drills.

Testing and Drills: We regularly test our emergency communication systems and procedures. For example, personal alarms are tested monthly to ensure the signal reaches the response receivers and staff know what sound/alert means. Fire drills are conducted at various times, including during off-peak hours, to practice what a lone worker would do (we might simulate a night shift scenario in a drill). These tests ensure that “all emergency procedures” work as intended and that lone workers can be contacted or can contact someone if a problem is identified. Any deficiencies noted (like a radio not reaching the basement) are fixed promptly (e.g., installing a signal booster or changing the procedure to require a second person for that task).

Through robust communication protocols, supervision proportional to risk, and thorough emergency planning, we strive to give lone workers confidence that help is always accessible and that they are never truly “alone” when it matters. CQC inspectors expect providers to “keep in touch” with lone staff and to respond to incidents appropriately, and this policy is designed to meet those expectations fully.

8. Use of Personal Safety Devices

{{org_field_name}} is committed to leveraging technology and equipment to enhance lone worker safety. We provide and maintain personal safety devices as control measures identified in risk assessments. Key points regarding these devices:

Personal Alarms: Many of our staff are issued portable personal alarm devices. These may be wearable pendants, belt-clip alarms, or hand-held units. When activated, these alarms send a distress signal. Depending on our system, it could set off an audible alarm to alert nearby colleagues or silently notify a monitoring system or emergency call center. Staff must carry their personal alarm whenever working alone, including moving around the building at night or in the grounds. Activation triggers have been explained – some devices have a panic button; others might have a pull cord or an automatic fall-detection (man-down) feature. We ensure staff know how to use their specific device.

Nurse Call System Integration: In resident areas, the nurse call system is also a lifeline for staff. In an emergency, staff can use the nearest call bell to summon assistance (for example, pressing multiple call buttons or a staff assist button if available, which can sound a distinct alarm). Our nurse call system is configured to alert the on-call person if activated when minimal staff are present. Procedures are in place that a call from certain zones, especially during lone working shifts, will be treated as a potential duress call for staff.

Radios / DECT Phones: We make use of wireless DECT phones and two-way radios to keep staff connected. As highlighted in industry best practice, devices like DECT phones are reliable on-site (not needing mobile signal) and can have panic functions. Each lone worker is assigned a device at the start of their shift. For example, a night nurse may have a handset that they carry room to room, allowing them to call the on-call manager or even other units in the organization instantly if needed. Some devices also allow broadcasting an emergency alert to all other handsets.

Buddy Systems and Electronic Check-ins: In addition to physical devices, we use procedural “devices” like a buddy system (pairing up staff to check on each other by calls or messages). We also have an electronic logging system where staff can check-in/out of lone working tasks via a smartphone app or the telephone. If the check-in is missed, it alerts a supervisor automatically. These systems act as a safety net ensuring no lone worker is forgotten or overlooked.

Maintenance of Devices: All safety equipment is regularly inspected and maintained. The manager (or delegated health and safety officer) keeps a schedule to test personal alarms, replace batteries, and ensure radios/phones are charged. Staff are reminded at the beginning of shifts to check that their device is working (for instance, perform a quick test call on a phone or a test activation of a personal alarm if the system allows non-emergency testing). If any device is found to be defective or missing, it must be reported immediately so a replacement can be provided. We never want an employee to be without their lifeline due to a malfunction.

Training and Usage Policy: Training is provided on how and when to use personal safety devices (see Training section below). Importantly, staff are reassured that using a panic alarm or calling for help will never be considered a bother or false alarm if done in good faith. We prefer a worker to activate an alarm at the earliest sign of trouble rather than wait until a situation worsens. Management monitors alarm usage to identify any patterns or frequent triggers – not to blame, but to see if more support or changes are needed in those situations. For example, if we see multiple alarms coming from one resident’s room, we’ll review that care plan and possibly adjust staffing.

Additional Safety Measures: Other devices in place include CCTV in common areas (monitored by the office or off-site security at night) which can be used to check on a lone worker’s safety if they are in view. We have security lighting and motion sensors around entrances – these not only deter intruders but can alert a lone worker to movement in an area. In some cases, personal GPS locator apps are offered on staff smartphones when they are out of the building (e.g., on an appointment), enabling the office to know their last location if they go missing. Any use of monitoring tech is done in consultation with staff and in line with privacy laws – its purpose is solely staff safety.

By equipping our staff with these personal safety devices and ensuring they are confident in their use, we significantly reduce the response time in emergencies and help lone workers feel safer. This aligns with HSE guidance that employers should provide means for lone workers to raise the alarm and be confident assistance will arrive. Embracing such technology and tools is part of our commitment to modern, effective safety practices in our care home.

9. Incident Reporting and Post-Incident Support

Despite all preventative measures, incidents may still occur. When they do, proper reporting and support are critical – both for the well-being of our staff and for learning how to improve safety.

Incident Reporting: All accidents, injuries, near misses, dangerous occurrences, or episodes of aggression that happen while working alone must be reported through {{org_field_name}}’s incident reporting system. This includes even seemingly minor incidents – for example, if a staff member felt threatened by a visitor while alone at reception, or if they slipped but caught themselves without injury. We encourage reporting of near misses because they are valuable warning signs. Staff should report incidents as soon as possible after they occur (once the immediate situation is made safe). The standard procedure is to inform the line manager or on-call manager immediately by phone for urgent issues, and then complete a written incident form or an electronic report before the end of the shift if able. If the lone worker is the one injured and cannot complete the form promptly, a supervisor will document preliminary details on their behalf and the full report can be completed once the individual is able.

We maintain confidentiality and a supportive tone in these reports – the purpose is not to assign blame to the staff member, but to understand what happened and what actions might prevent a recurrence. In line with a “no blame” culture, staff are actively encouraged to report incidents and hazards without fear of reprisal. CQC’s Regulation 17 (Good Governance) expects providers to have systems to record and investigate safety incidents and to act on them, which we rigorously follow.

Management will review each lone working incident report and investigate as needed. Investigations may involve interviewing the staff involved, speaking with witnesses (if any), examining any equipment involved, and reviewing camera footage if available. The goal is to identify root causes and whether additional controls or changes in procedure are required. For example, an investigation might reveal that a personal alarm didn’t reach far enough in the garden area – prompting us to extend the alarm range or adjust the policy that staff shouldn’t go out of range. Or if a resident attacked a lone staff, the investigation might lead to updating that resident’s care plan or increasing staffing at certain times.

Notification and External Reporting

The Registered Provider and Registered Manager must ensure that incidents are reported to external authorities where the relevant statutory reporting criteria are met. Internal incident reporting does not replace any statutory duty to notify an external body.

RIDDOR

Where an accident or incident is work-related, the Registered Manager or other person responsible for health and safety reporting must determine whether it is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).

Reportable events include, where the statutory criteria are met:

An act of non-consensual physical violence towards a member of staff is reportable under RIDDOR where it is work-related and results in death, a specified injury or incapacity from normal work for more than seven consecutive days.

An injury resulting in more than three consecutive days of incapacity must be recorded where the applicable record-keeping requirement applies, even where it does not meet the over-seven-day reporting threshold.

The person responsible for RIDDOR reporting must ensure that reports are made within the applicable statutory timescale.

Police

The police must be contacted immediately where there is an emergency requiring police assistance. Non-emergency criminal matters must be reported appropriately in accordance with the circumstances and the provider’s procedures.

Where an incident occurring while services are being provided, or as a consequence of carrying on the regulated activity, is reported to or investigated by the police, the Registered Manager must also consider the corresponding statutory CQC notification requirement and submit a notification where required.

Safeguarding

Where an incident raises a concern that a person using the service has experienced, is experiencing or is at risk of abuse or neglect, the provider must take immediate protective action and follow the local adult safeguarding procedure in accordance with the Care Act 2014 and the provider’s safeguarding policy.

Safeguarding action does not replace any separate duty to notify CQC, the police or another statutory body.

CQC Statutory Notifications

The registered person must notify CQC without delay of incidents that meet the requirements of the Care Quality Commission (Registration) Regulations 2009.

Relevant notifications may include:

A staff injury by itself is not automatically a CQC-notifiable serious injury because the statutory serious-injury provisions relate to people using the service. However, the circumstances surrounding a staff injury may trigger another notification requirement, for example where the incident is reported to or investigated by the police or where it threatens the safe operation of the regulated activity.

The Registered Manager must ensure that a clear record is maintained of statutory notifications made and of decisions concerning whether a statutory notification was required.

Post-Incident Support for Staff: {{org_field_name}} recognizes that being involved in an incident while alone can be frightening and stressful. After any such event, we prioritize the staff member’s well-being:

Immediately after an incident, first aid or medical treatment will be arranged for any injuries. The staff member will be relieved from duty if they need to recover or if they are shaken – we will call in extra staff or the on-call manager will step in to ensure the service remains covered so the individual can rest.

The manager (or a senior person) will debrief with the staff as soon as possible, typically within 24 hours. This debrief is an open, supportive discussion of what happened, what feelings or concerns the staff has, and reassurance of their safety and the next steps. It’s also an opportunity for the staff to suggest what could help them feel safer in future.

We offer counselling or emotional support resources, especially for traumatic incidents. This might include access to an Employee Assistance Programme (if available) where confidential counselling can be sought, or referral to occupational health services. Even if no physical harm occurred, the psychological impact of, say, a near-attack can be significant. Managers will check in on the staff’s mental well-being in the days and weeks after, adjusting their duties temporarily if needed (for example, pairing them with another staff for a while if they feel nervous working alone subsequently).

Peer Support: We encourage a team culture where colleagues reach out to someone who experienced a scary incident. The staff member’s co-workers and supervisors should be understanding if they are shaken or need to talk it out. We do not tolerate any ridicule or minimization of someone’s feelings about an incident. Instead, we might organize a brief team discussion (without breaching confidentiality) to reaffirm the importance of safety and that everyone has each other’s back.

Learning and Improvement: After the incident investigation is complete, management will share relevant findings and changes with the team. For instance, if a new protocol is introduced or an existing one reinforced (like “always carry the portable phone into Room 12 because of its location”), that will be communicated. Positive recognition is also given – if the lone worker handled the situation well by following procedures (e.g., they used their training to de-escalate or they triggered the alarm appropriately), we will acknowledge that. This reinforces trust in the safety system and confidence that incidents can be managed.

In cases where the incident involved a resident, we will simultaneously ensure the resident is reviewed – including any new measures to manage their behavior, possibly involving specialist input, for the safety of all. If the incident was due to environmental factors (like a trip hazard), that hazard will be immediately addressed.

Our ultimate aim after any incident is to make sure the staff member is okay and to prevent similar events. CQC inspectors will look at how we handle adverse events – under the Safe and Well-led domains, they expect that providers learn from incidents and support their staff. This policy’s approach to incident reporting and follow-up is designed to meet those expectations and, more importantly, to uphold our duty of care to our employees.

10. Training and Ongoing Support for Staff

Proper training and support are fundamental in enabling staff to work safely and confidently on their own. In line with Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations, we ensure that all staff receive the training, supervision, and professional development necessary for their roles, including the challenges of lone working. Our approach includes:

Induction Training: Every new employee (and temporary or agency staff working in our home) undergoes an induction program that covers lone working safety. This induction will familiarize them with this policy, the risks associated with working alone, and the controls in place. Topics include: awareness of potential hazards when alone, personal security, boundaries of what they should not do alone, how to use communication devices and alarms, emergency procedures (fire, medical, security) when alone, and conflict management basics. For example, new staff are taught how to carry out a quick “dynamic risk assessment” in unexpected situations and to always have an exit plan in mind when entering potentially risky scenarios.

Statutory Learning Disability and Autism Training

{{org_field_name}}, as a provider registered with the Care Quality Commission, will ensure that every person working for the purposes of the regulated activities carried on by the provider receives training on learning disability and autism that is appropriate to their role.

This requirement applies to staff working at all levels of the organisation for the purposes of the regulated activity. The provider will determine the level and content of training required according to each person’s role and responsibilities and will ensure that the training meets the requirements of the Health and Social Care Act 2008, as amended by the Health and Care Act 2022, and the current statutory Code of Practice on learning disability and autism training.

The provider will have regard to the Oliver McGowan Code of Practice on statutory learning disability and autism training when arranging, delivering and reviewing this training. Training records will be maintained and the provider will monitor completion, suitability to role and any requirement for further or updated training.

The Registered Manager must ensure that staff are not treated as competent solely because they have completed a training course. Where a role requires practical competence, knowledge or skills to be demonstrated, appropriate assessment, supervision and support must also be provided.

Personal Safety and Conflict De-Escalation Training: We provide specialized training in personal safety techniques. This involves recognizing warning signs of aggression, understanding body language, techniques for calming an agitated person, and how to safely break away and escape if physically grabbed. Staff also learn verbal de-escalation skills and how to handle challenging conversations without inflaming the situation. These skills are crucial when one is alone with a potentially aggressive individual. Additionally, scenario-based role play is used – for instance, handling an aggressive resident in a mock situation – so that staff can practice responses while they have backup, building muscle memory for when they are truly alone.

Use of Equipment Training: Any device or alarm system provided to lone workers is covered in training sessions. We ensure staff can confidently operate two-way radios, phones, alarm pendants, fire extinguishers, etc. If we introduce new technology (say, a new lone worker alert app or a updated nurse-call handset), we will provide update training. Staff must demonstrate in practice sessions that they know how to, for example, activate their personal alarm and what to say when the call is connected. We also cover what to do if a device fails (like knowing the location of landline telephones as backup).

First Aid and Health Emergency Training: Being alone means a staff might be the only one able to provide immediate aid in an emergency. We ensure that an adequate number of staff (especially those frequently on night duty alone) are trained in first aid. Lone workers get refreshers on handling common emergencies like falls, choking, or cardiac arrest using basic life support techniques, as well as how to swiftly get further help. This not only protects residents but also prepares staff to manage until help arrives. Training also touches on self-care – for instance, how to assess if they need immediate help and how to communicate that (like using a phrase “I need help for myself” to emergency services).

Mental Health and Stress Management: Lone working can be isolating and sometimes stressful. We include in our training awareness about the potential psychological impacts of lone work – such as increased stress or feeling of vulnerability. Staff are educated on strategies to manage stress (proper breaks, mindfulness techniques, confidence-building) and are assured that it’s okay to speak up if they feel overwhelmed. We point out resources for mental well-being and encourage a supportive team ethos, so no one feels they must “just cope” silently. Supervisors will keep an eye on staff morale and stress levels, especially for those who do a lot of night shifts or challenging one-to-one assignments. Regular conversations about how they’re finding lone work are part of supervision.

Refresher and Continuous Training: Training is not one-off. We schedule periodic refreshers (at least annually) for key topics like fire safety, personal safety, and emergency response to keep knowledge current. If regulations change or if an incident suggests a training gap, we update our programs promptly. For example, if we had an incident where a lone worker didn’t follow the expected procedure, we might realize we need a refresher for all on that procedure. We also incorporate learnings from others – e.g., if an industry alert comes out about lone worker safety or a new piece of guidance from Skills for Care or HSE, we discuss it in team meetings.

Competency and Limit Setting: We explicitly train staff on understanding their own limits and the policy’s limits for lone working. This means reinforcing messages like “Do not attempt what you’ve not been trained to do, especially alone” and “If you feel unsure, stop and get advice.” We empower staff to say no in situations where they feel it’s unsafe. Part of training is case studies: discussing past real scenarios (anonymized) either from our home or others, analyzing what went right or wrong. This helps staff internalize the reasoning behind the rules. CQC emphasizes that staff should have the “qualifications, competence, skills and experience to do [care] safely” – our training regime is built to ensure this is true for lone working contexts.

Documentation and Policy Access: This Lone Working Policy and related safe working procedures are readily accessible to staff (kept in our policy manual and on the staff intranet, if available). Managers will regularly remind staff to review it, especially if changes have been made. We may hold brief quizzes or Q&A during meetings to ensure understanding (for example, “What would you do if…?” scenarios).

Ongoing Support: Beyond formal training, the management provides ongoing support through an open-door policy for discussing safety concerns. If at any time a staff member feels they need additional support or a refresher before doing something alone, they can approach a supervisor without judgement. For instance, a new night staff might request to shadow an experienced colleague for a couple of nights to build confidence – we will accommodate that. Mentoring and buddy systems during initial period are encouraged: new hires or those new to lone tasks get paired with veteran staff who can share tips and be a phone contact for questions.

Consultation and Involvement: We involve staff in developing our lone working practices. Through staff meetings, health and safety committee, or informal feedback, employees can suggest improvements or express what makes them feel safer. This collaborative approach ensures the training and procedures remain practical and address real issues faced on the floor.

Investing in comprehensive training and continuous development of our staff not only meets regulatory requirements but also demonstrates our duty of care as an employer. A well-trained, confident worker is far less likely to encounter problems, and far more likely to handle them effectively if they do. CQC inspectors will often interview staff to gauge their understanding of safety protocols – we are confident that through our training efforts, any staff member working alone in our home will be able to clearly articulate the risks and controls in place, and feel supported by their organization.

11. Relevant Legislation, Regulations and CQC Requirements

This Lone Working and Staff Safety Policy is underpinned by the legislation and regulatory requirements applicable to health and social care providers and employers in England.

Health and Safety at Work etc. Act 1974

{{org_field_name}} has a duty, so far as is reasonably practicable, to protect the health, safety and welfare at work of its employees. This includes staff who work alone or without close or direct supervision.

The provider must maintain safe systems of work, appropriate information, instruction, training and supervision and a working environment that is safe so far as is reasonably practicable.

Management of Health and Safety at Work Regulations 1999

The provider must carry out suitable and sufficient assessments of risks to employees and others affected by its undertaking and implement appropriate preventive and protective measures.

Lone-working risks must therefore be identified and assessed before lone working is authorised. Assessments must be reviewed where there is reason to suspect that they are no longer valid or where there has been a significant change in the matters to which they relate.

The provider must also maintain appropriate arrangements for effective planning, organisation, control, monitoring and review of preventive and protective measures and establish procedures for serious and imminent danger.

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013

{{org_field_name}} will report work-related deaths, specified injuries, applicable occupational diseases, specified dangerous occurrences and over-seven-day worker incapacitation where the statutory RIDDOR criteria are met.

Work-related acts of non-consensual violence are reportable where they result in death, a specified injury or more than seven consecutive days of incapacity from the worker’s normal duties.

Incidents that do not meet the threshold for reporting will nevertheless be recorded where the applicable statutory record-keeping requirement applies and in accordance with the provider’s own incident procedures.

Regulatory Reform (Fire Safety) Order 2005

The provider must maintain a suitable and sufficient fire risk assessment and appropriate fire precautions for the premises.

Staffing arrangements, including any lone-working or reduced-staffing arrangement, must be compatible with the home’s fire risk assessment, emergency plan and the evacuation needs of people using the service.

Staff must receive appropriate fire-safety information, instruction and training and must understand the home’s approved evacuation arrangements.

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

The Health and Social Care Act 2008 establishes the regulatory framework within which the Care Quality Commission regulates health and adult social care services in England.

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended, contain the Fundamental Standards applicable to registered providers and registered managers.

The following regulations are particularly relevant to this policy.

Regulation 12 – Safe Care and Treatment

Care and treatment must be provided safely.

The provider must assess risks to the health and safety of people using the service and do all that is reasonably practicable to mitigate those risks.

Persons providing care and treatment must have the qualifications, competence, skills and experience necessary to do so safely. Premises and equipment must also be safe for their intended use.

Lone-working arrangements must therefore not expose a person using the service to unsafe care or prevent staff from following the person’s care plan, risk assessment or required staffing arrangements.

Regulation 13 – Safeguarding Service Users from Abuse and Improper Treatment

People using the service must be protected from abuse and improper treatment.

Where violence, aggression or other behaviour raises a safeguarding concern for a person using the service, the provider must take appropriate action in accordance with Regulation 13 and applicable safeguarding procedures.

Regulation 13 is concerned with safeguarding people using the service. Employer responsibilities for protecting staff from workplace violence arise principally under health and safety legislation.

Regulation 17 – Good Governance

The provider must establish and operate effective systems and processes to ensure compliance with regulatory requirements.

These systems must enable the provider to assess, monitor and improve the quality and safety of services and to assess, monitor and mitigate risks relating to the health, safety and welfare of people using the service and others who may be at risk from the carrying on of the regulated activity.

The provider must maintain appropriate records and use incidents, near misses, audits and other information to identify risks and make improvements.

Lone-working risk assessments, incidents, staffing decisions and resulting actions must therefore be appropriately documented and subject to management oversight.

Regulation 18 – Staffing

Sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed to meet the requirements of the Fundamental Standards.

Staff must also receive appropriate support, training, professional development, supervision and appraisal necessary to enable them to perform their duties.

There is no general statutory minimum staffing ratio specifically for lone working in care homes. Staffing must instead be determined according to people’s assessed needs, risks, required care, staff competence, the environment and foreseeable emergencies.

Lone working must not be used where it would prevent the provider from deploying sufficient staff or meeting people’s assessed needs safely.

Regulation 20 – Duty of Candour

Where an incident involving a person using the service meets the statutory definition of a notifiable safety incident, the provider must comply with the duty of candour requirements, including the applicable notification, explanation, apology and record-keeping requirements.

The duty of candour under Regulation 20 is a duty towards people using the service, or their relevant representative where applicable. It must not be confused with the provider’s separate duty to support an employee following a workplace incident.

Statutory Learning Disability and Autism Training

Section 181 of the Health and Care Act 2022 amended the Health and Social Care Act 2008 to introduce a statutory requirement for CQC-registered service providers to ensure that people working for the purposes of their regulated activities receive learning disability and autism training appropriate to their role.

{{org_field_name}} will comply with this requirement and have regard to the current statutory Code of Practice concerning learning disability and autism training.

The Oliver McGowan Code of Practice on statutory learning disability and autism training became final on 6 September 2025 and sets out standards relevant to meeting this statutory requirement.

Care Quality Commission (Registration) Regulations 2009

The provider must comply with the statutory requirements to notify CQC of specified changes, events and incidents.

For the purposes of this policy, Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 is particularly relevant. It requires the registered person to notify CQC without delay of specified incidents, including relevant serious injuries to people using the service, abuse or allegations of abuse, incidents reported to or investigated by the police and specified events that prevent or threaten to prevent the provider from carrying on the regulated activity safely.

The Regulation 18 notification requirement under the Care Quality Commission (Registration) Regulations 2009 must not be confused with Regulation 18, Staffing, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Care Act 2014

Where an incident gives rise to a concern that an adult with care and support needs is experiencing, or is at risk of, abuse or neglect and the applicable statutory safeguarding criteria are met, the provider will cooperate with the relevant local authority safeguarding process and take immediate action to protect the person.

Equality Act 2010

{{org_field_name}} will comply with its duties under the Equality Act 2010, including making reasonable adjustments for disabled workers where the statutory duty applies.

A person’s disability or health condition must not automatically exclude them from lone working. The provider will assess relevant risks individually and, where appropriate, obtain occupational health or other competent advice and make reasonable adjustments.

UK GDPR and Data Protection Act 2018

Where personal information is processed for lone-worker monitoring or staff-safety purposes, including through electronic monitoring, location information, CCTV, check-in systems or incident investigations, {{org_field_name}} will ensure that the processing is lawful, fair, transparent, proportionate and appropriately secure.

Staff will be given appropriate privacy information explaining the relevant monitoring, its purpose and the way in which their personal information is used and retained.

Health and Safety Consultation Requirements

{{org_field_name}} will consult employees or their appointed or elected safety representatives about health and safety matters in accordance with applicable health and safety consultation legislation.

Staff will be encouraged to contribute to lone-working risk assessments and reviews and to raise safety concerns without fear of disadvantage for doing so.

HSE Lone-Working Guidance

{{org_field_name}} will have regard to current Health and Safety Executive guidance on protecting lone workers.

The provider’s arrangements will include appropriate risk assessment, training, supervision, monitoring, communication and emergency arrangements. The provider will set clear limits on what may safely be undertaken alone and ensure that lone workers can obtain assistance when required.

CQC Regulatory Guidance and Assessment

{{org_field_name}} will maintain compliance with the applicable statutory regulations irrespective of changes to CQC’s inspection or assessment methodology.

The provider will keep under review current CQC guidance relevant to safe care and treatment, staffing, governance, safeguarding and statutory notifications and will update this policy when a change in legislation or regulatory guidance requires a change in practice.

Evidence available to CQC will include, where relevant, lone-working risk assessments, staffing assessments, staff training and competency records, supervision records, incident and near-miss records, audits, action plans and evidence that identified improvements have been implemented and reviewed.

12. CQC Single Assessment Framework – evidence we will maintain


We recognise that CQC assesses services using the Single Assessment Framework and will expect clear evidence that lone working is safe, well-managed and reviewed. To support inspections and continuous improvement, we will maintain evidence including:

up-to-date lone working risk assessments (by role/area/shift), including night staffing arrangements;

training and competency records for staff expected to work alone;

records of check-in systems, on-call arrangements, and equipment testing;

incident/near-miss logs, investigations, learning actions and audit outcomes; and

minutes/records showing staff consultation and how concerns were acted upon.
These records will be reviewed through our governance systems and used to demonstrate a positive safety culture and continuous improvement.

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