1. What the regulation says
Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))
assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))
doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))
ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely, (Reg 12(2)(c) (staff competence))
where equipment or medicines are supplied by the service provider, ensuring that there are sufficient quantities of these to ensure the safety of service users and to meet their needs, (Reg 12(2)(f) (sufficient equipment + medicines supply))
the proper and safe management of medicines, (Reg 12(2)(g) (medicines management))
Regulation 18 adds the staffing and competence duties that this policy relies on:
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 the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/18. Where this policy and the regulation diverge, the regulation wins.
2. Plain-English summary
Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Alongside this, Regulation 18 requires you to deploy enough suitably qualified, competent, skilled and experienced staff, and to give them appropriate support, training, professional development, supervision and appraisal. For medical emergencies and deterioration, this means trained staff, available and checked equipment and emergency medicines where required, and a reliable escalation route.
3. Purpose
The purpose of this policy is to make sure that [Service Name] can recognise, respond to and escalate medical emergencies and deterioration promptly and safely.
Medical emergencies may happen in any regulated service, including clinics, treatment rooms, diagnostic services, dental services, patient transport, care homes, domiciliary care and specialist services. The service must have clear arrangements, trained staff, available equipment, emergency medicines where required, and a reliable escalation route.
This policy supports Regulation 12 safe care and treatment, Regulation 17 good governance, Regulation 18 staffing, Regulation 15 premises and equipment, and the provider's duty to protect people from avoidable harm.
4. Policy warning
A medical emergency must never be treated as an ordinary appointment, visit, transport problem or administrative event.
Where a person is acutely unwell, deteriorating, collapsed, experiencing serious symptoms, or appears to need urgent assessment, staff must act immediately, call emergency services where required, and escalate to the senior person on duty.
Delay in recognising or escalating deterioration can cause serious harm and may require incident reporting, safeguarding review, duty of candour, CQC notification or professional-regulatory referral.
5. Scope
This policy applies to emergencies and deterioration involving:
- people using the service
- visitors
- staff
- contractors
- people being transported
- people receiving care at home where staff are present
- people attending clinics, treatment rooms, diagnostic services or procedures
It includes:
- collapse
- cardiac arrest
- respiratory distress
- anaphylaxis
- seizure
- choking
- severe bleeding
- suspected stroke
- chest pain
- sepsis concern
- hypoglycaemia or diabetic emergency
- deterioration after a procedure
- reaction to medicine, contrast, vaccine or local anaesthetic
- mental health crisis where there is immediate risk
- severe pain or sudden change in condition
- any situation where staff are concerned that urgent medical help may be needed
6. Principles
The service will make sure that:
- staff know how to recognise deterioration
- staff know how to call for help
- emergency equipment is available and checked
- emergency medicines are available where required by service type
- staff work within their competence
- staff receive training appropriate to their role
- emergency arrangements are tested and reviewed
- incidents are recorded and learned from
- emergency decisions are documented clearly
The service will not ask staff to manage an emergency beyond their training, competence or role.
7. Responsibilities
The Registered Manager is responsible for ensuring that emergency arrangements are in place, staff are trained, equipment and medicines are checked, and incidents are reviewed.
Clinical leads or competent senior staff are responsible for advising on service-specific emergency risks, emergency medicines, equipment, training and escalation routes.
All staff are responsible for recognising concerns, calling for help, following local procedures and recording what happened.
The provider or Nominated Individual is responsible for ensuring that the service has the resources needed for safe emergency preparedness.
8. Emergency risk assessment
The service must assess the likely emergency risks linked to its regulated activities.
The assessment must consider:
- type of service provided
- procedures or treatments offered
- medicines used or administered
- age and needs of people using the service
- clinical complexity
- known allergies and contraindications
- premises layout
- lone working
- travel or transport
- access to emergency services
- staff skill mix
- equipment needed
- emergency medicines needed
- out-of-hours arrangements
The emergency risk assessment must be reviewed annually and whenever the service model changes.
9. Recognising deterioration
Staff must be alert to signs of deterioration, including:
- sudden collapse
- difficulty breathing
- chest pain
- blue lips or severe pallor
- confusion or reduced consciousness
- new weakness or facial droop
- seizure
- severe allergic reaction
- uncontrolled bleeding
- severe pain
- abnormal observations where observations are taken
- rapid worsening of condition
- staff, family or patient concern that something is seriously wrong
Where staff are worried, they must escalate. Staff must not wait for a complete set of observations before calling for help if the person appears seriously unwell.
10. Immediate response
In a medical emergency, staff must:
- stay calm and call for help
- make the area safe
- assess responsiveness and breathing where trained to do so
- call 999 where emergency help is required
- start basic life support where trained and indicated
- use emergency equipment where trained and appropriate
- give emergency medicines only where trained, authorised and appropriate
- follow local emergency procedure
- keep the person under observation
- communicate clearly with emergency services
- provide relevant records, medicines information and known allergies
- inform the Registered Manager or senior lead
- record the event as soon as possible
Staff must not leave the person alone unless this is necessary to get urgent help and there is no safer alternative.
11. Calling emergency services
Staff must call 999 immediately where there is:
- cardiac arrest
- severe breathing difficulty
- suspected stroke
- chest pain suggestive of heart attack
- anaphylaxis
- seizure that is prolonged or unusual for the person
- serious injury
- severe bleeding
- loss of consciousness
- severe deterioration
- suspected sepsis or life-threatening infection
- serious concern about immediate safety
Where staff are unsure, they must err on the side of safety and seek urgent advice.
12. Basic life support
Staff whose role requires basic life support must receive training at a level appropriate to their role and service type.
The service must identify:
- which staff require basic life support training
- whether adult, child or infant life support is needed
- refresher frequency
- whether scenario-based practice is required
- who can use the defibrillator
- how competence is recorded
Training must be recorded on the training matrix.
13. Emergency medicines
Where emergency medicines are required by the service type, procedure or risk assessment, the service must ensure that they are:
- available
- in date
- stored safely
- checked regularly
- appropriate to the service
- accessible in an emergency
- used only by staff who are trained and authorised
- recorded after use
- replenished immediately after use or expiry
The service must have a separate Emergency Medicines and Equipment Checking Policy or procedure.
14. Emergency equipment
Emergency equipment must be available where required by the service type and risk assessment.
This may include:
- first aid kit
- oxygen
- suction
- airway equipment
- automated external defibrillator
- bag-valve-mask device
- emergency trolley or grab bag
- anaphylaxis kit
- blood glucose equipment
- emergency call bell or alert system
- evacuation aids
- procedure-specific emergency equipment
Equipment must be checked, maintained and replaced in line with the service's checking procedure.
15. Handover to emergency services
When emergency services arrive, staff must provide a clear handover including:
- person's name and date of birth
- what happened
- time symptoms or incident started
- observations where available
- relevant medical history
- allergies
- medicines
- treatment or first aid already given
- risks or safeguarding concerns
- next of kin or representative details where appropriate
- relevant care plan, clinical record or treatment notes
The handover must be documented.
16. Communication with family or representatives
The Registered Manager or senior person must decide who should be informed and when.
Where appropriate and lawful, the service must inform:
- family
- representative
- advocate
- next of kin
- commissioner
- placing authority
- GP or relevant clinician
The record must show who was informed, when, by whom and what information was shared.
17. Recording
After a medical emergency, the service must record:
- date and time
- location
- person affected
- presenting symptoms or incident
- staff present
- immediate action taken
- emergency services contacted
- medicines or equipment used
- observations taken
- advice received
- handover given
- people informed
- outcome
- incident reference
- whether safeguarding, duty of candour, CQC notification, RIDDOR or other reporting was considered
Records must be factual, timely and complete.
18. Incident review and learning
Every medical emergency must be reviewed as an incident.
The review must consider:
- whether the emergency was recognised promptly
- whether escalation was timely
- whether staff followed procedure
- whether equipment and medicines were available
- whether staff had the required competence
- whether records were complete
- whether communication was effective
- whether duty of candour applied
- whether external notification was required
- whether learning or action is needed
Findings must be added to the action plan or risk register where appropriate.
19. Staff support
Staff involved in a medical emergency must be offered support and debriefing.
The debrief must consider:
- what happened
- what went well
- what was difficult
- staff wellbeing
- whether further training is needed
- whether the emergency procedure needs changing
Support does not replace investigation where there are concerns about practice.
20. Testing and drills
The service must test emergency arrangements at least annually, or more often where risk requires.
Testing may include:
- scenario drill
- call-bell test
- emergency grab-bag check
- defibrillator access check
- emergency handover practice
- anaphylaxis scenario
- collapse scenario
- evacuation scenario
Tests must be recorded and actions tracked.
21. Related policies
This policy should be read with:
- Safe Care and Treatment Policy
- Emergency Medicines and Equipment Checking Policy
- Incident Reporting, Investigation and Learning Policy
- Risk Management and Risk Register Policy
- Action Plan and Improvement Tracking Policy
- Medicines Policy
- Infection Prevention and Control Policy
- Training, Competency and Mandatory Training Policy
- Business Continuity and Emergency Preparedness Policy
- CQC Statutory Notifications Policy
- Duty of Candour Policy
- Record Keeping Policy
22. Review
This policy will be reviewed annually, or sooner following a medical emergency, serious incident, CQC finding, equipment failure, medicines incident, change in service type, change in national guidance or emergency drill finding.
23. 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.
- CQC Regulation 12: Safe care and treatment
- CQC Regulation 18: Staffing
- Resuscitation Council UK
- NICE sepsis and deterioration guidance
- Sector-specific emergency guidance relevant to your service type
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/12)
24. 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.
25. Document control
| Version | Date | Author | Changes |
|---|---|---|---|
| v1 | 2026-06-10 | Verivius (sample) | Initial sample template, conformed to the Verivius policy standard. |
This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.