CHW192-On-Call Person Policy

Registration Number: {{org_field_registration_no}}

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 those working evening, night, weekend, and bank holiday shifts, as well as those assigned to on-call duties as part of the management or senior care team. It ensures that staff always have access to competent advice, managerial support, and escalation channels regardless of the time or day, particularly when Registered Manager or senior managers are not physically present.

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}} is committed to maintaining a 24/7 operational oversight structure through an effective on-call rota. The on-call person is a competent and experienced member of the management or senior care team who is contactable at any time during their on-call period. The on-call system provides a vital link between frontline staff and the Registered Manager or Responsible Individual and ensures continuity in decision-making, safeguarding responses, emergency management, and service-user support.

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 for:
Providing advice and support to staff in managing incidents, emergencies, or concerns
Authorising urgent decisions relating to staffing, admissions, access, or care
Guiding staff through safeguarding reporting processes
Escalating issues to the Registered Manager or Responsible Individual if they are serious or cannot be resolved
Making arrangements for urgent repairs, maintenance, or health-related emergencies
Reviewing reports of incidents and following up to ensure appropriate documentation and actions
Attending the home physically if necessary, based on the nature or severity of the issue
Logging all calls and interventions made during the on-call period for handover and audit purposes

7. Responsibilities of Staff Contacting the On-Call Person

Staff are expected to contact the on-call person in a timely manner when:
There is an emergency, accident, or serious incident
A safeguarding concern or allegation arises
There are staffing shortages or last-minute absences that impact safe care
A resident requires hospital admission, or there is a death in the service
There is a fire alarm, utility failure, or other environmental emergency
There is uncertainty regarding a decision that requires senior oversight
Staff must ensure they provide clear and concise information, follow any instructions given, and record the outcome of the call in the relevant documentation. Staff should not delay contacting the on-call person where there is risk or uncertainty.

8. Safeguarding and Emergency Procedures

If the concern relates to the welfare of a service user and meets the threshold for abuse or neglect, the on-call person will guide staff through initial safeguarding measures, including ensuring the individual is safe, separating alleged perpetrators, and recording facts. The on-call person must decide if an immediate referral to {{org_field_local_authority_authority_name}} or out-of-hours safeguarding is required. In cases of medical emergency, the on-call person supports staff in contacting emergency services and liaising with family, hospital staff, or other professionals. All actions must be logged in accordance with CHW13 – Safeguarding Adults from Abuse Policy and CHW24 – Management of Incidents Policy.

9. Logging, Reporting, and Handover

The on-call person maintains an on-call log recording all calls received, actions taken, decisions made, and any follow-up required. This log is reviewed daily by the Registered Manager and used to ensure proper oversight, learning, and audit. Serious incidents or safeguarding matters are escalated in writing the next working day and reported in accordance with CIW regulations and our notification policy (CHW25). Where patterns emerge, the Registered Manager incorporates findings into quality improvement plans.

10. Training and Competency

Only staff who have completed on-call training and demonstrated sufficient knowledge of operational procedures, safeguarding, emergency management, and leadership are placed on the on-call rota. Training includes scenario planning, escalation protocols, and regulatory responsibilities. Competency is assessed through supervision, shadowing, and performance reviews. The Registered Manager reviews the performance of on-call staff regularly and provides feedback, support, and refresher training as needed.

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 effectiveness of the on-call system is reviewed as part of our Quality of Care Review and internal audits. This includes analysis of on-call logs, response times, feedback from staff, and outcomes of decisions made. Improvements are implemented where gaps are identified, and CIW is provided with evidence of robust out-of-hours governance when requested.

13. Policy Review

This policy will be reviewed annually, or earlier if there are significant incidents, changes in legislation, feedback from CIW, or changes in service structure. The review is led by the Registered Manager in consultation with on-call staff and the Responsible Individual.

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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