Lone Working SOP

This Standard Operating Procedure (SOP) establishes the framework by which Lakeside Physiotherapy Ltd, an independent physiotherapy practice operating from fixed clinic premises in Carlisle, Cumbria, manages the risks associated with lone working. The practice is an independent limited company and is in the process of registering with the Care Quality Commission (CQC) under the new Single Assessment Framework (2024). Lone workers face the same hazards as other workers, but there is a greater risk of those hazards causing harm because they may not have anyone to help or support them if something goes wrong. At Lakeside Physiotherapy, lone working situations arise primarily when a clinician conducts a treatment session with a patient in the absence of other staff members, or when staff are present on premises outside of normal business hours. This SOP has been prepared in response to the most current UK regulatory position as of April 2026. The Health and Safety Executive (HSE) has recently updated its guidance on lone working and has formally integrated psychosocial risks — including stress and burnout arising from isolated working — into its routine inspection framework. New providers applying to register with the CQC will be assessed using questions aligned to the 34 Quality Statements under the Single Assessment Framework. This SOP therefore addresses the requirements of both regulatory bodies.

The purpose of this SOP is to ensure that all staff at Lakeside Physiotherapy Ltd who work alone — whether alone with patients or on premises in the absence of colleagues — do so within a structured, documented, and risk-managed framework that satisfies the requirements of the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999, and the CQC's Quality Statement on safe systems, pathways and transitions. The specific objectives are to: • Establish a clear, documented, and enforceable framework for identifying situations in which staff may be considered lone workers • Fulfil the Practice's statutory duties as an employer under current UK health, safety, and data protection legislation • Provide practical, step-by-step procedures that staff can follow before, during, and after any period of lone working • Demonstrate compliance to the CQC, the HSE, and any other relevant regulatory inspector • Protect both staff and patients, including those who are vulnerable adults or who present with mental health conditions, from avoidable harm arising from inadequate lone working arrangements

This SOP applies to all employees, contractors, students, and volunteers working at or on behalf of Lakeside Physiotherapy Ltd. It applies to: • All clinical staff conducting patient-facing appointments without a colleague present on the premises • All administrative or clinical staff working on practice premises before or after normal clinic hours • Any member of staff undertaking domiciliary or home visit appointments This SOP applies at all times, including evenings, weekends, and Bank Holidays. It applies regardless of the employment status of the individual — employed, self-employed, or on a placement basis.

Lone Worker: Any member of staff who works in a situation where they cannot be seen or heard by another colleague, or where they are working in a location where help is not immediately available in an emergency. Vulnerable Adult: Any person aged 18 or over who is or may be in need of community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of themselves, or unable to protect themselves against significant harm or exploitation (Care Act 2014). Psychosocial Risk: A risk arising from the organisation of work, including factors such as isolation, lack of communication, stress, or unclear responsibilities that may affect the psychological health and wellbeing of a lone worker. Responsible Person: The designated member of staff or manager responsible for maintaining contact with and monitoring the welfare of a lone worker during a lone working episode.

This SOP has been prepared with reference to the following current UK legislation and regulatory guidance: • Health and Safety at Work etc. Act 1974 • Management of Health and Safety at Work Regulations 1999 (as amended) • Lone Working — Guidance for Employers (HSE, updated 2025) • Working Alone: Health and Safety Guidance (HSE INDG73) • HSE Management Standards for Work-Related Stress (updated 2026 — now includes psychosocial risk assessment requirements for lone workers) • Care Quality Commission — Single Assessment Framework (2024): Quality Statement — Safe Systems, Pathways and Transitions • Care Quality Commission — Single Assessment Framework: Quality Statement — Safe Environments • UK General Data Protection Regulation (UK GDPR) 2021 • Data (Use and Access) Act 2025 — implications for electronic patient records accessed during lone working episodes • Safeguarding Vulnerable Groups Act 2006 • Care Act 2014

The following risk factors have been identified as particularly relevant to lone working at Lakeside Physiotherapy Ltd and must be addressed in individual lone working risk assessments: • Treatment of patients presenting with mental health conditions — heightened risk of unpredictable behaviour; additional safeguards must be in place including a pre-appointment welfare check • Occasional treatment of vulnerable adults — capacity assessment considerations and appropriate consent procedures must be followed in accordance with the Mental Capacity Act 2005 • Working on premises outside normal business hours — increased risk of delayed emergency response; the Responsible Person must be contactable throughout • Psychosocial risk — HSE 2026 guidance requires that lone working risk assessments specifically consider the psychological impact of isolation; all lone workers must have access to the practice's Employee Assistance Programme • Patient aggression or challenging behaviour — all clinical staff must have completed conflict resolution and de-escalation training

All staff required to lone work must have completed the following before undertaking any lone working: • Lone Working Induction — provided by the Clinical Lead on commencement of employment and reviewed annually • Conflict Resolution and De-escalation Training — minimum every 3 years • Basic Life Support — minimum every 12 months • Safeguarding Adults — Level 2 minimum, refreshed every 3 years • Mental Capacity Act Awareness — on induction and every 3 years Training records must be maintained in the Practice's HR system. The Clinical Lead is responsible for monitoring training compliance and ensuring staff are not permitted to lone work if their mandatory training has lapsed.

The effectiveness of this SOP will be monitored through: • Monthly review of the Lone Working Register by the Clinical Lead — checking that all lone working episodes have been properly documented and all check-in procedures followed • Quarterly audit of lone working risk assessments — ensuring they remain current and reflect any changes in staff, patients, or working arrangements • Annual SOP review — the Practice Director will review this SOP annually and following any significant incident, near miss, or change in relevant legislation or regulatory guidance • CQC compliance review — this SOP will be reviewed against the current CQC Quality Statements at each annual review cycle

All lone working episodes must be recorded in the Lone Working Register, which must include: the date and time of the episode; the name of the lone worker; the location; the start and end times; confirmation that check-in and check-out procedures were followed; and any concerns or incidents arising. Any incident, near miss, or concern arising during a lone working episode must be reported immediately to the Clinical Lead and recorded in the Practice's Incident Log in accordance with the Incident Reporting and Investigation SOP. Reportable injuries or dangerous occurrences must be reported to the HSE under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR). All records must be retained for a minimum of 7 years in accordance with the Practice's Document Retention Policy and UK GDPR obligations.

This SOP is subject to review no less than annually, or following: • Any significant incident or near miss involving a lone worker • Any material change to the Practice's working arrangements • Any change in relevant UK legislation or CQC/HSE regulatory guidance • Any change in the registered manager or Practice Director This document is owned by the Practice Director of Lakeside Physiotherapy Ltd. Version control is maintained in the Document Change Log at the end of this document.

This SOP should be read in conjunction with the following Practice documents: • Health and Safety Policy • Safeguarding Adults Policy • Incident Reporting and Investigation SOP • Risk Assessment Policy • Data Protection and UK GDPR Policy • Mental Capacity Assessment SOP • Staff Supervision and Appraisal Policy External references: • HSE Lone Working Guidance (hse.gov.uk) • CQC Single Assessment Framework (cqc.org.uk) • legislation.gov.uk — Health and Safety at Work etc. Act 1974