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Registration Number: {{org_field_registration_no}}

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On-Call Person Policy

1. Purpose

The purpose of this policy is to ensure that a robust and responsive on-call system is in place at {{org_field_name}} to provide managerial oversight, decision-making support, and guidance to care staff outside of normal working hours. This policy supports the delivery of safe, high-quality care at all times, in line with the Regulation and Inspection of Social Care (Wales) Act 2016, The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, and the expectations of Care Inspectorate Wales (CIW). It outlines how the on-call system is organised, the responsibilities of the on-call person, and how staff should utilise the support available to manage emergencies, safeguarding concerns, and operational challenges effectively.

2. Scope

This policy applies to all staff at {{org_field_name}}, including staff working evenings, nights, weekends and bank holidays, and to any member of the management or senior care team who is assigned to undertake on-call duties.

The on-call arrangement provides staff with access to competent managerial advice, support and escalation outside normal management hours. It does not transfer, replace or reduce the statutory responsibilities of the service provider, Responsible Individual or Registered Manager.

The Responsible Individual remains responsible for ensuring that suitable arrangements are in place for the effective management of the service whenever there is no Registered Manager or the Registered Manager is not present at the service, in accordance with Regulation 72 of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

Where the Registered Manager is absent, the on-call arrangements must operate alongside the service’s formal deputising and management arrangements so that the service continues to be managed safely and effectively, individuals are supported to achieve their personal outcomes, disruption to the service is minimised and the requirements of the Regulations continue to be met.

3. Related Policies

This policy should be read in conjunction with:
CHW04 – Good Governance
CHW11 – Safe Care and Treatment Policy
CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
CHW18 – Risk Management and Assessment Policy
CHW19 – Emergency and Business Continuity Plan
CHW24 – Management of Accidents, Incidents, and Near Misses Policy
CHW25 – Notification of Other Incidents Policy

4. Policy Statement

{{org_field_name}} will maintain effective arrangements for managerial support and escalation outside normal management hours so that staff can obtain timely advice and support when managing emergencies, safeguarding concerns, staffing difficulties, significant incidents and other operational matters.

The designated on-call person must be a suitably competent and experienced member of the management or senior care team who has been authorised to undertake the functions allocated to them under this policy.

The on-call person acts on behalf of the service within the limits of their role, competence and delegated authority. Undertaking on-call duties does not make that person the Responsible Individual or Registered Manager and does not transfer to them any statutory responsibility that the Regulations place specifically upon the service provider, Responsible Individual or Registered Manager.

The on-call arrangements must support, and not replace, the management arrangements established by the Responsible Individual for periods when the Registered Manager is absent or not present at the service.

Where an issue exceeds the on-call person’s competence, authority or role, or where the matter presents a significant risk to the safety or well-being of an individual or to the safe operation of the service, it must be escalated without delay to the Registered Manager, Responsible Individual or other person identified within the service’s management escalation arrangements.

5. On-Call Rota and Availability

A rota is created monthly and includes the name and contact number of the designated on-call person for each day, including overnight, weekends, and public holidays. The rota is displayed in staff areas and made available in the handover file and care office. The on-call person must be contactable by phone throughout their shift and able to respond within 15 minutes. The on-call duty includes the hours outside of the Registered Manager’s physical presence, including overnight and weekend periods. If for any reason the on-call person cannot fulfil their duty, they must inform the Registered Manager immediately so a replacement can be arranged without delay.

6. Responsibilities of the On-Call Person

The on-call person is responsible, within the limits of their competence, role and delegated authority, for:

• providing timely advice and support to staff who are managing incidents, emergencies, safeguarding concerns or significant operational difficulties;
• supporting decisions required to maintain safe staffing and the continuity of care and support;
• ensuring that staffing concerns which may affect the safety or well-being of individuals are escalated appropriately and that arrangements are made to maintain sufficient numbers of suitably qualified, trained, skilled, competent and experienced staff;
• supporting staff to implement the service’s safeguarding procedures and ensuring that safeguarding concerns are acted upon without delay;
• ensuring immediate action is taken to protect individuals where there is an allegation, evidence or reasonable concern of abuse, neglect or improper treatment;
• supporting appropriate referrals to the local authority safeguarding service, police, emergency services or other relevant agencies in accordance with the circumstances and the service’s safeguarding procedures;
• escalating serious, unresolved or significant matters to the Registered Manager and, where appropriate, the Responsible Individual without delay;
• arranging or authorising urgent repairs, maintenance or other emergency measures within the limits of their delegated authority;
• supporting staff to obtain emergency medical assistance or other professional healthcare support where required;
• reviewing information about incidents reported during the on-call period and ensuring that appropriate immediate actions and records have been completed;
• attending the service where this is necessary because the matter cannot safely or effectively be managed remotely and attendance falls within the person’s role and competence;
• maintaining an accurate record of calls received, advice provided, decisions made, actions taken, matters escalated and any follow-up required; and
• providing an effective handover of outstanding matters to the Registered Manager or appropriate manager.

The on-call person must not make decisions outside their competence or delegated authority.

Any decision concerning an admission or commencement of a service must comply with the service’s Admissions and Commencement of Service Policy and Regulation 14 of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended. An on-call person may only undertake or authorise such a decision where they have the required competence, training and organisational authority and the required assessment and suitability determination has been completed.

The on-call person’s involvement does not remove the responsibilities of staff to contact emergency services, make safeguarding referrals or take other immediate action where this is required to protect an individual from harm.

7. Responsibilities of Staff Contacting the On-Call Person

Staff must contact the on-call person promptly where managerial advice, authorisation, support or escalation is required outside normal management hours.

Circumstances requiring contact may include:

• a serious accident, incident or significant deterioration in an individual’s condition;
• a safeguarding concern, allegation or suspected abuse, neglect or improper treatment;
• staffing shortages or unexpected absences which may affect the service’s ability to provide safe care and support;
• an unplanned hospital admission or other significant healthcare event;
• the death of an individual;
• a fire, flood, utility failure, security incident or other environmental emergency;
• failure of essential equipment or premises which may affect the safety of individuals;
• an incident involving the police or emergency services;
• circumstances which may prevent, or could prevent, the service from continuing to operate safely;
• a significant medication incident;
• an unexpected event requiring senior management oversight; or
• uncertainty about an operational decision where delay could adversely affect the safety or well-being of an individual.

Contacting the on-call person must never delay emergency action.

Where there is an immediate risk to life or serious harm, staff must contact the emergency services first and take all reasonable immediate action within their role and competence to protect individuals.

Where a safeguarding concern requires immediate referral under the Wales Safeguarding Procedures or local safeguarding arrangements, staff must make or facilitate that referral without waiting for permission from the on-call person. The on-call person must be informed as soon as practicable so that appropriate management oversight and further action can take place.

Staff contacting the on-call person must provide clear, accurate and relevant information about the circumstances, the individuals affected, immediate risks, actions already taken and any further assistance required.

Staff must follow lawful and appropriate instructions given by the on-call person and must make the required records in the individual’s care records, incident records, safeguarding records or other applicable service documentation. An entry in the on-call log does not replace any other record required by legislation, regulation or the service’s policies and procedures.

8. Safeguarding and Emergency Procedures

Where there is an allegation, evidence or reasonable concern that an individual has experienced, or may be at risk of, abuse, neglect or improper treatment, staff must act immediately in accordance with CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy, the Wales Safeguarding Procedures and applicable local safeguarding arrangements.

Immediate action must prioritise the safety and well-being of the individual and any other person who may be at risk. Depending upon the circumstances, this may include:

• obtaining emergency medical assistance;
• contacting the police or other emergency services;
• taking reasonable action to remove or reduce an immediate risk;
• ensuring that an alleged perpetrator does not have inappropriate access to the individual or other individuals, where this can lawfully and safely be achieved;
• preserving evidence where a criminal offence may have occurred;
• making an appropriate safeguarding referral to {{org_field_local_authority_authority_name}} or the relevant out-of-hours safeguarding service; and
• accurately recording the concern, allegation or evidence, immediate action taken and any referrals made.

Staff must not delay an urgent safeguarding referral or other immediate protective action while waiting to contact, or obtain permission from, the on-call person.

The on-call person must support staff to follow the safeguarding procedure, confirm that immediate risks have been addressed and ensure that the matter is escalated to the Registered Manager and, where appropriate, the Responsible Individual. The on-call person must not investigate safeguarding allegations unless specifically authorised to do so within the relevant safeguarding process.

Where the circumstances require a notification to Care Inspectorate Wales or another statutory body, the matter must be escalated immediately so that the notification can be made within the statutory timescale.

In a medical emergency, staff must contact the appropriate emergency service or healthcare professional without delay. Contact with the on-call person must not delay access to emergency treatment.

Communication with relatives, representatives or other persons following an incident must take account of the individual’s wishes, confidentiality, capacity, best interests where applicable, safeguarding requirements and any directions given by the police, local authority or other investigating body.

All actions, decisions, referrals, professional advice and outcomes must be recorded in accordance with CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy, CHW24 – Management of Accidents, Incidents and Near Misses Policy and any other applicable service record.

9. Logging, Reporting and Handover

The on-call person must maintain an accurate and contemporaneous on-call record for each contact or significant matter dealt with during the on-call period.

The record must include, as applicable:

• the date and time of the contact;
• the name and role of the person making contact;
• the individual or service area concerned;
• the nature of the incident, concern or request for advice;
• any immediate risks identified;
• advice or instructions provided;
• decisions made and the rationale for those decisions;
• actions already taken and further actions required;
• referrals to external agencies or professionals;
• escalation to the Registered Manager, Responsible Individual or other senior person;
• whether the matter may require notification to Care Inspectorate Wales or another statutory body;
• any outstanding actions; and
• details of the subsequent handover.

The on-call record is an additional management record and does not replace accident and incident records, safeguarding records, care records, medication records, statutory notifications or any other record required by legislation, regulation or the service’s policies and procedures.

Any incident or event which may require notification to Care Inspectorate Wales must be escalated without delay to the Registered Manager, Responsible Individual or other person authorised under the service’s notification arrangements.

Where The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, require a notification to be made without delay, the service must not postpone the notification until the next working day solely because the incident occurred outside normal office hours.

Notifications to Care Inspectorate Wales must be made within the applicable statutory timescale, in writing and in the manner and form required by Care Inspectorate Wales, normally through CIW Online.

Where an authorised person submits a notification on behalf of the Responsible Individual or service provider, this administrative delegation does not transfer the statutory accountability of the person or body upon whom the Regulations place the notification duty.

The on-call person must ensure that matters requiring follow-up are handed over promptly to the Registered Manager or appropriate manager. Significant safeguarding matters, serious incidents, staffing risks and other unresolved safety concerns must not simply be left for routine handover where earlier escalation is necessary.

Records arising from on-call activity must be available for management oversight, audit, identification of patterns and trends and the service’s quality monitoring arrangements.

10. Training and Competency

Only persons who have been assessed by {{org_field_name}} as having the appropriate knowledge, skills, competence, experience and authority to undertake the on-call role may be included on the on-call rota.

Completion of on-call training alone does not establish competence to undertake the role.

Before undertaking on-call duties independently, the person must demonstrate sufficient understanding, appropriate to the functions allocated to them, of:

• the service’s statement of purpose and management structure;
• the limits of their own role and delegated authority;
• safeguarding legislation, the Wales Safeguarding Procedures and local safeguarding arrangements;
• emergency procedures and business continuity arrangements;
• safe staffing requirements and escalation arrangements;
• accident and incident management;
• arrangements for obtaining urgent healthcare support;
• Care Inspectorate Wales notification arrangements and the requirement for specified notifications to be made within the applicable statutory timescale;
• record-keeping and confidentiality requirements;
• the service’s relevant policies and procedures; and
• the circumstances in which the Registered Manager, Responsible Individual, emergency services or other statutory agencies must be contacted.

Where the on-call person’s role includes undertaking or making decisions based upon a statutory assessment, admission decision or other specialist function, the person must also possess any specific competence and training required for that function.

Competence must be assessed before a person undertakes on-call duties independently and reviewed through supervision, observation, review of on-call records, appraisal and other appropriate management processes.

Where a concern is identified regarding an on-call person’s competence, knowledge or performance, the Registered Manager must take appropriate action, which may include additional supervision, training, shadowing, restriction of delegated responsibilities or removal from the on-call rota until satisfactory competence is demonstrated.

11. Professional Conduct and Support

The on-call person is expected to conduct themselves professionally, remain calm and objective, and ensure all decisions prioritise the safety, dignity, and rights of individuals. They are supported by the Registered Manager and Responsible Individual, who are available for second-line escalation when needed. The emotional wellbeing of the on-call team is supported through debriefs and reflective supervision, particularly after managing critical incidents.

12. Quality Assurance and Audit

The Registered Manager will monitor the operation of the on-call system to ensure that it remains effective in supporting the safe and consistent operation of the service.

Monitoring will include, where applicable:

• review of on-call records;
• the nature and frequency of incidents and concerns arising outside normal management hours;
• safeguarding matters;
• staffing difficulties;
• emergency events;
• recurring operational problems;
• the appropriateness and timeliness of decisions and escalation;
• completion of required records and notifications;
• actions arising from incidents;
• feedback from staff; and
• evidence of recurring themes, risks or learning.

Where concerns, trends or deficiencies are identified, appropriate remedial action must be taken and monitored to completion.

Information arising from the on-call system which relates to incidents, notifiable incidents, safeguarding matters, concerns, complaints or risks to the quality or safety of the service must be made available to the Responsible Individual for the purposes of their regulatory oversight.

The Responsible Individual must ensure that relevant information from the on-call system is considered as part of the systems established under Regulation 80 of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, for monitoring, reviewing and improving the quality of care and support.

The statutory quality-of-care review must be undertaken as often as required and at least every six months and must include consideration of relevant aggregated information about incidents, notifiable incidents, safeguarding matters, whistleblowing, concerns and complaints.

Any learning identified from on-call incidents must be used, where appropriate, to improve policies, procedures, staff training, risk management, staffing arrangements and the quality and safety of the service.

13. Policy Review

This policy will be reviewed at least annually and earlier where required because of:

• a change in legislation, regulations, statutory guidance or relevant Care Inspectorate Wales requirements;
• a significant incident, safeguarding matter or emergency;
• identified learning from on-call records, audits or quality monitoring;
• a change in the statement of purpose, management structure or service arrangements;
• a regulatory inspection finding or requirement; or
• evidence that the policy is no longer operating effectively.

The Registered Manager is responsible for coordinating the operational review of this policy.

The Responsible Individual must ensure that suitable arrangements are in place to ensure that this policy is kept up to date, having regard to the statement of purpose and the requirements of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

Any material changes must be communicated to relevant staff and incorporated into training, supervision or other implementation arrangements where necessary.

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