Standards › Standard 29 › Standard operating procedures (SOPs)
Procedure · HC-SOP-009 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 29.31
At a glance
- Each client with a single caregiver has a coverage plan for when that caregiver is unavailable (HC-PLN-001).
- A named alternative is set for each client.
- The client and family are told the alternative before the gap.
- The plan is tested on each change of caregiver.
- Stop and get help straight away if: a client is left without any care for two days when the only caregiver is sick.
1. Purpose
To make sure no client is left without care when their only caregiver is absent (29.31).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A client served by one caregiver who falls sick or goes on leave is left with no care. A written cover plan keeps the client safe in the absence.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Home care service lead | Owns the coverage plan | Clinician or manager |
| Care coordinator | Arranges the named alternative | Staff |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Plan cover.
- Name the alternative caregiver for each solo client on HC-PLN-001.
Key point: Planned.
Step 2. Inform.
- Tell the client and family the alternative before any gap.
Key point: Informed.
Step 3. Test.
- Test the plan on each change of caregiver.
Key point: Tested.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Solo-caregiver clients with a named alternative | 100% | Quarterly | Home care service lead | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HC-PLN-001 | Solo caregiver coverage plan | Plan |
| MOB-REG-002 | Coverage review register (existing, reused) | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global strategy and action plan on ageing and health 2016-2030, WHO Integrated care for older people (ICOPE) guidelines (2017), and WHO guidance on migrant health. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)