Sample policy · Ambulance

Crew welfare, fitness for shift and driving hours policy (ambulance)

Statutory anchor: Regulation 18 (staffing), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). The primary law governing driving hours and crew fatigue is road traffic and working-time law, principally Regulation (EC) No 561/2006 (retained), the Road Transport (Working Time) Regulations 2005 and the tachograph rules; this policy also engages Regulation 12 (safe care and treatment). · primary source

1. What the regulation says

Sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed in order to meet the requirements of this Part. (Reg 18(1): the headline duty)

receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform. (Reg 18(2)(a): support, training, supervision and appraisal)

The full text of Regulation 18 is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/18. The primary driving-hours duties sit in road traffic and working-time law (Regulation (EC) No 561/2006, the Road Transport (Working Time) Regulations 2005 and the tachograph rules), and the applicable limits depend on vehicle type, passenger seats, weight, PSV status, route type, commercial use and any exemption, so the Service checks the current GOV.UK drivers' hours and tachograph guidance before setting rota, route and relief arrangements. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

You have to deploy enough suitably qualified, competent, skilled and experienced staff to meet Part 3. Staff have to receive appropriate support, training, professional development, supervision and appraisal. Where staff are health or social-care registered professionals, they have to be enabled to give their regulator evidence of meeting professional standards.

Separately, crew fitness for shift and driving hours are governed by road traffic and working-time law. Staff must not calculate driving-hours limits from memory; they must check the current statutory and GOV.UK source material before agreeing long-distance, standby, event-cover or multi-leg shifts.

3. Purpose

This policy sets out how the Service checks crew fitness for shift, manages fatigue and illness, records driving-hours controls and supports Staff after assault, patient death, road traffic collision or another serious event.

The policy is written for independent ambulance services where scheduled transfers, urgent journeys, event cover and vehicles over 3.5 tonnes may create driving-hours and welfare risks.

4. Scope

This policy applies to:

This policy does not replace the Service's employment contract, occupational health process, disciplinary policy, health and safety policy or legal advice.

5. Fitness for shift

The Service checks that Crew are fit to work before they start patient-facing duty.

5.1 Pre-shift self-declaration

Crew confirm before shift that they are fit to work.

The declaration covers:

Crew must tell the Operations Manager if anything changes during the shift.

5.2 Manager review of fitness concerns

Where a fitness concern is raised, the Operations Manager:

The Service treats fatigue and illness as safety issues before they become performance issues.

5.3 Intoxication on shift

If Staff suspect that a crew member is intoxicated on shift, they escalate immediately.

The Operations Manager:

The Service does not allow the person to return to duty until the review and return-to-work decision are complete.

5.4 Operational fitness concern workflow

When a fitness concern arises before or during a shift, Staff use this workflow:

  1. Stop the risk: prevent driving, patient handling or clinical work where the concern may affect safety.
  2. Protect current patients: arrange replacement cover, a safe stopping point or clinical escalation without leaving a patient unsupported.
  3. Record facts: document what was reported or observed, the time, the work affected and any immediate action. Do not record unsupported conclusions.
  4. Obtain advice: involve the Operations Manager and seek clinical, occupational-health, HR, DVSA or emergency advice as the circumstances require.
  5. Make the duty decision: record whether the person is removed, restricted, redeployed or permitted to continue, who made the decision and why.
  6. Close the loop: set welfare follow-up, evidence needed for return to duty and any incident, supervision, rota or improvement action.

No manager may use staffing pressure as the reason to override an unresolved safety concern.

6. Driving-hours and tachograph control

The Service identifies which vehicles and journeys are covered by assimilated drivers' hours rules, domestic rules, working-time rules or tachograph requirements.

Driver-hours rules depend on vehicle type, passenger seats, weight, PSV status, route type, commercial use and any exemption. The Service must not apply a single nine-hour rule without checking the current GOV.UK drivers' hours and tachograph guidance.

The Operations Manager records:

Staff do not calculate driving-hours limits from memory. They check the current statutory and GOV.UK source material before agreeing long-distance, standby, event-cover or multi-leg shifts.

7. Welfare after assault or serious incident

The Service supports Crew after assault, patient death, road traffic collision, clinical deterioration, cardiac arrest, safeguarding event or another serious event.

7.1 Crew assault

If a crew member is assaulted, Staff:

The Service does not normalise assault as part of ambulance work.

7.2 Serious incident welfare follow-up

After a serious incident, the Operations Manager or delegated manager:

The incident review separates staff welfare from performance review. Staff can need support even where their actions were appropriate.

8. Responsibilities

9. Recording requirements

Each fitness, fatigue or driving-hours exception is recorded without delay. The record should include:

Health information is limited to what is necessary for the safety and employment decision and is access-controlled. The Service also keeps the following records:

Records are kept in the Service governance records and are available for internal review, CQC review, commissioner review and external review where required.

10. Audit cadence

The Service uses the following Verivius default audit rhythm unless current drivers' hours, tachograph, working time, CQC, RIDDOR, commissioner or local source material requires a different rhythm:

Audit findings are recorded as improvement actions with an owner and review date.

11. Version control and review date

The Service keeps a controlled copy of this policy. The footer or document-control table records:

12. Related policies and records

Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.

13. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

14. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

15. Document control

Version Date Author Changes
v1.2 2026-07-21 Verivius (sample) Expanded the exception record to evidence working time, immediate restrictions, welfare support and safe return to duty.
v1.1 2026-07-19 Verivius (sample) Added the operational fitness workflow, exception evidence fields and linked companion policies.
v1 2026-06-10 Verivius (sample) Conformed existing draft to the Verivius policy standard; added statutory anchor, verbatim Regulation 18 quotes, plain-English summary, sources and document control. Operational sections preserved.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

An independent ambulance service is one of the few settings where the person receiving care is a passenger in a vehicle driven by the same crew who are treating them. A patient on a long transfer, an event standby or a multi-leg journey cannot choose another crew, step out of a vehicle driven by someone too tired to be safe, or read the drivers' hours rules for the vehicle they are in. Two failures do the harm here: a fatigued, ill or impaired crew member put on the road because cover was thin, and a driving-hours limit run from memory rather than from the current source for that vehicle class, which turns on weight, seats, route and tachograph status and is not a single remembered figure. The evidence trail is what protects the person, because they are carried rather than consulted. The pre-shift fitness record shows they were handed to a crew fit to drive and to care, the driving-hours and tachograph record shows the journey was planned inside the law rather than pushed through to hold the rota together, and the welfare record after an assault or a collision shows the service supported the crew who will carry the next patient. Regulation 18 is the CQC anchor, but the teeth here are road traffic and working-time law, and none of it is safe run from memory.

  1. A crew member who declares themselves unfit, or whom a manager judges unfit, is actually taken off driving and patient-facing work, not simply logged as a concern while the shift carries on. The pre-shift declaration is a live decision that can change the rota, not a box ticked at sign-on, and no manager uses thin cover as the reason to keep an unresolved safety concern on the road.

    Strong evidence: The pre-shift fitness declaration for the crew member and shift, with the Operations Manager's record where a concern was raised: what was reported or observed, the work stopped or restricted, who decided and why, and the return-to-duty steps set. The self-declaration and its cadence are Verivius defaults; the duty not to drive while unfit rests on the driver under road traffic law.

    Weak evidence: A run of identical 'fit' declarations with no concern ever recorded across months of shifts, which reads as a signature exercise rather than an honest check. Where a concern does appear, the fitness log names it but the rota shows the same person driving the same job that day with the removal field blank, or the only trace of a fatigue worry is a sympathetic line in a supervision note with no owner, no restriction and no review point.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  2. Before a long-distance, standby, event-cover or multi-leg shift is agreed, the service identifies which drivers' hours and tachograph regime the vehicle and journey fall under from the current statutory and GOV.UK source, and records the driver, the licence category, the planned driving and duty time, the rest and relief plan and the tachograph evidence where it is required. The limits are read from the live source for that vehicle class, not run from memory or from a single remembered rule.

    Strong evidence: The driving-hours control record the Operations Manager keeps per journey: vehicle weight category, whether tachograph rules apply, the driver and licence category, planned driving and duty time, the rest and break plan, any second-driver or relief arrangement, and the tachograph evidence retained where the vehicle requires it, checked against the current GOV.UK drivers' hours and tachograph guidance rather than a fixed figure. The evidence includes a fleet register recording each vehicle's passenger-seat capacity, maximum permissible mass, operational use, any emergency, rescue or specialised-medical-vehicle exemption relied on, the applicable drivers' hours, tachograph and working-time regime, and the source and date of that determination.

    Weak evidence: A single limit applied across every job regardless of vehicle class, passenger seats, weight or route, with no note of which regime was checked or when. The tell is a rota built to a remembered figure with the source never cited, tachograph evidence missing for vehicles that need it, or a long relief-less run agreed under staffing pressure with no rest plan recorded against it.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 12(1), reg 12(2)(a)-(b) and reg 18(1). The card tests that the service has classified each vehicle and documented the applicable transport regime; which regime applies (assimilated drivers' hours, the GB domestic rules or working-time requirements, with emergency, rescue and specialised-medical-vehicle exemptions) is a transport-law determination for the service to make and record.

  3. A suspected intoxication on shift stops the person from driving and patient-facing work at once and makes the patient, crew and public safe, and each separate onward duty is then weighed on its own. A police, Driver and Vehicle Standards Agency, professional-regulator, commissioner or CQC consideration is recorded as a distinct decision, because acting on one of them does not discharge any of the others, and the person does not return to duty until the review and return-to-work decision are complete.

    Strong evidence: The intoxication incident record: the immediate stop and safe removal, how the patient and public were made safe, the factual evidence preserved, and a separate line for each onward consideration weighed (police, Driver and Vehicle Standards Agency, professional regulator, commissioner, CQC), with the return-to-work decision recorded before any redeployment.

    Weak evidence: An incident noting the person was 'sent home' with no record of who covered the patient or how the scene was made safe. Or a single closure line stating the matter was 'dealt with by HR', with the police, licensing, professional-registration and CQC questions collapsed into one tick or left blank, so it cannot be shown that each was actually considered on its own.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  4. After an assault, a patient death, a road traffic collision or another serious event, the crew member is offered genuine welfare support that is recorded and kept separate from any review of their performance, because a person can need support even where everything they did was right. Where the assault caused injury, whether it is reportable to the Health and Safety Executive is tested as its own duty, separate from any CQC notification and from the crew member's own report to the police.

    Strong evidence: The welfare and debrief record: the immediate welfare check, the decision on whether the person continued the shift, the debrief offered, occupational-health or counselling signposting, any time away from duty, and follow-up scheduled, held apart from performance review. For an assault, the separate consideration of whether the injury is reportable to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR), which logging the incident locally does not discharge. A separately recorded assessment of whether the statutory duty of candour threshold was met, identifying the applicable provider definition and the action taken, kept separate from any RIDDOR report, CQC statutory notification, police report or professional-regulator referral.

    Weak evidence: An assault or serious incident that survives only as a line in the incident log, the welfare fields blank, so it cannot be shown anyone checked the crew member was alright. Support folded into a disciplinary or capability conversation so the two cannot be told apart, or a RIDDOR consideration left empty on an assault that plainly caused injury, treated as if the incident entry were the report.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  5. A crew member removed for fatigue, illness, intoxication or the effect of a serious incident comes back through a recorded decision against set criteria, made by the right person, not by the individual simply saying they feel ready. The record shows what had to be true before they drove or handled a patient again, who assessed it and the outcome.

    Strong evidence: The return-to-duty record: the criteria set when the person was removed, the reassessment against them, any occupational-health, clinical or HR advice relied on, the approver, and the outcome, linked back to the original fitness, intoxication or incident record.

    Weak evidence: A person back on the rota the next shift with no return-to-duty entry at all, or a bare 'fit to return' note with no criteria, no assessor named and no advice recorded where the removal clearly warranted it. The gap is sharpest where someone removed for suspected intoxication or after a serious assault reappears driving with nothing showing how that decision was reached.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  6. Each fitness, fatigue, driving-hours, intoxication or assault exception is recorded at the time with the concern, the immediate restriction, the decision and its reasons, the welfare follow-up and the return-to-duty criteria, and the health information in it is limited to what the safety and employment decision needs and access-controlled. The weekly and monthly reviews then read these entries for pattern, so a run of fatigue on one rota line or repeated assaults at one booking surfaces as a fixable cause rather than sitting as a monthly count.

    Strong evidence: The exception records with their decision and welfare fields complete and health information access-controlled, plus the Operations Manager's weekly review of fatigue, rota gaps and driving-hours concerns and the Registered Manager's monthly review of assaults, serious incidents, sickness patterns and return-to-duty decisions, with findings carried to improvement actions that have an owner and a review date.

    Weak evidence: Exception records that stop at the concern with the decision, reasons and welfare follow-up blank, or health detail copied in wholesale and readable by anyone with rota access. Reviews that table a count of incidents with no breakdown by rota line, route or booking and no repeat cause escalated, so the same fatigue pattern or the same assault-prone job recurs cycle after cycle with nothing done between.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

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Last verified 23 July 2026

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Last reviewed 21 July 2026