Standards › Standard 28 › Standard operating procedures (SOPs)
Procedure · LTC-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 28.23
At a glance
- Each resident transfer is assessed and planned, and the equipment and staff needed are set (LTC-FRM-005).
- Manual lifting of residents is avoided where equipment or extra staff can be used.
- Staff are trained in safe handling before they transfer residents.
- Every manual handling injury is reported and reviewed.
- Stop and get help straight away if: staff transfer a heavy resident by hand alone when a hoist is needed.
1. Purpose
To prevent manual handling injuries to staff and residents from transfers (28.23).
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
Health workers can catch infections and be hurt at work, and they can also carry infections to patients. Protecting their health, with required vaccinations and safe working conditions, protects everyone in the building.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for long-term care | Owns the handling rule and training | Clinician or manager |
| Care staff | Assess and carry out each transfer safely | 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. Assess.
- Assess the transfer and record the method, equipment and staff needed.
Key point: Assessed.
Step 2. Equip and train.
- Use the equipment set, and confirm the staff are trained in safe handling.
Key point: Equipped.
Step 3. Report.
- Report every manual handling injury and review it.
Key point: Reported.
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 |
|---|---|---|---|---|
| Transfers with a recorded method and equipment | 100% | Monthly | Clinical lead for long-term care | 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 |
|---|---|---|
| LTC-FRM-005 | Manual handling and transfer risk record | Record |
| WRK-SOP-002 | Occupational exposure and injury response (existing, reused) | Procedure |
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 digital and AI governance. |
| 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)