Emergency / On Call

Is there a robust and clearly communicated on-call rota ensuring trained personnel are available at all times outside office hours?

What we look for: Review the on-call rota for the last 3 months to ensure there are no gaps in cover. Good practice shows clear contingency plans if the primary on-call person falls ill. A fail would be gaps in the rota or assigning on-call duties to inexperienced staff without backup.

Evidence: On-call rota, staff communication records, on-call policy

Do on-call staff have secure, immediate access to up-to-date client care plans, risk assessments, and staff contact details?

What we look for: Test the remote access capabilities of the on-call equipment to verify live access to client and staff data. Good practice ensures secure, GDPR-compliant access to electronic care records. A fail would be on-call staff relying on outdated paper summaries or being unable to access critical risk assessments in an emergency.

Evidence: On-call mobile/laptop audit, digital system access logs, BCP access

Do records show that on-call staff correctly escalate medical emergencies, safeguarding alerts, and incidents?

What we look for: Review out-of-hours incidents requiring escalation to emergency services or local authorities. Check that on-call staff act promptly and correctly follow local safeguarding protocols. A fail would be an on-call worker leaving a safeguarding alert to be dealt with the next working day rather than taking immediate protective action.

Evidence: Incident reports, safeguarding referrals, local authority notifications

Is there an effective daily handover process ensuring all out-of-hours incidents are reviewed by the management team the next working day?

What we look for: Check how on-call information flows back to the core office team on a Monday morning or after a bank holiday. Good practice involves a structured handover meeting where follow-up tasks are assigned. A fail is an absence of formal handover leading to missed follow-ups on out-of-hours issues.

Evidence: Morning handover meeting notes, email handovers, task allocation records

Is there a clear procedure followed by on-call staff to manage and cover sudden staff sickness to prevent missed visits?

What we look for: Cross-reference staff sickness reports with out-of-hours logs to see how care was reallocated. Good practice involves dynamic risk assessment prioritizing critical visits and keeping clients informed of delays. A fail would be visits dropping off the system resulting in a missed visit due to inadequate out-of-hours coordination.

Evidence: Missed visit policy, on-call logs covering sickness, unallocated visit reports

Are all incoming on-call queries, emergencies, and actions taken accurately documented in a central log?

What we look for: Sample 10 random out-of-hours entries from the last quarter to check for detail, timeframes, and clear outcomes. Good logs detail the exact time, caller, issue, advice given, and subsequent actions. A fail would be fragmented, missing, or illegible on-call notes that do not explain how issues were resolved.

Evidence: Out of hours logs, electronic call management system, on-call record books

Do on-call staff have immediate access to the Business Continuity Plan and understand how to activate it during a major incident?

What we look for: Ask an on-call staff member how they would handle a systemic IT failure or extreme weather event out of hours. They must know where the BCP is and how to invoke it. A fail would be the BCP only being accessible on the office server with no offline backup for the on-call team.

Evidence: Business Continuity Plan, on-call staff competency checks, emergency contacts list

Does the registered manager regularly audit the on-call logs to identify trends, response times, and areas for service improvement?

What we look for: Look for evidence that management analyzes out-of-hours data (e.g., peak call times, frequent staff sickness, repeat client falls). Good practice uses this data to adjust rotas or provide targeted training. A fail is treating on-call logs purely as a diary with no overarching analysis or continuous improvement.

Evidence: Quarterly on-call audits, management meeting minutes, quality improvement plans