Standards › Standard 29 › Policies
Policy · HC-POL-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 29.23
At a glance
- Each caregiver has a discreet way to signal distress or ask for help during a visit (HC-SOP-007).
- A caregiver who feels unsafe can leave and report without confrontation.
- Lone-worker check-ins follow MOB-SOP-002.
- Each signal is responded to and recorded.
- Stop and get help straight away if: a caregiver is threatened and has no way to call for help.
1. Purpose
To give caregivers a discreet way to call for help while working alone (29.23).
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 caregiver alone in a home who feels threatened needs a way to ask for help without the client or family knowing. A discreet signal, and a plan for it, keeps them safe.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Home care service lead | Owns the signal system | Clinician or manager |
| Caregiver | Uses the signal and reports | 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. Set the signal.
- Agree a discreet signal or check-in with each caregiver.
Key point: Set.
Step 2. Respond.
- Respond to each signal at once and arrange support or withdrawal.
Key point: Responded.
Step 3. Record.
- Record each signal and the response on MOB-FRM-004.
Key point: Recorded.
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 |
|---|---|---|---|---|
| Caregivers with a discreet signal in place | 100% | Monthly | 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 |
|---|---|---|
| MOB-FRM-004 | Lone working check-in log (existing, reused) | Record |
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)