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Registration Number: {{org_field_registration_no}}

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Management of Accidents, Incidents, and Near Misses Policy

1. Purpose

The purpose of this policy is to establish a structured and efficient approach to the management, reporting, investigation, and prevention of accidents, incidents, and near misses within {{org_field_name}}. By implementing a clear reporting system and proactive safety measures, we ensure the health, safety, and well-being of service users, staff, and visitors while complying with Care Quality Commission (CQC) regulations and Health and Safety Executive (HSE) guidelines.

This policy ensures that all accidents, incidents, and near misses are appropriately recorded, investigated, and used to implement preventative measures, fostering a culture of continuous improvement and risk reduction.

2. Scope

This policy applies to:

• All employees, including care workers, administrative staff, and management.
• Service users and their families, ensuring a safe care environment.
• Visitors, contractors, and third-party service providers.
• Regulatory bodies, including CQC and local health authorities, ensuring compliance.

It covers:

• Definitions of accidents, incidents, and near misses.
• Reporting and documentation procedures.
• Investigation and root cause analysis.
• Preventative and corrective actions.
• Staff training and responsibilities.
• Compliance monitoring and continuous improvement.

3. Legal and Regulatory Framework

This policy aligns with the following legal and regulatory requirements:

• Health and Safety at Work etc. Act 1974 – general duties to prevent harm.
• Management of Health and Safety at Work Regulations 1999 – risk assessment and control measures.
• Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013 – legal duties and time limits for reporting certain work-related events to HSE.
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 12 (Safe care and treatment) and Regulation 20 (Duty of candour).
• Care Quality Commission (Registration) Regulations 2009 – Regulation 16 (Notification of death of a service user) and Regulation 18 (Notification of other incidents).
• Care Act 2014 (Section 42) and Care and Support Statutory Guidance – adult safeguarding duties and multi-agency working.
• UK GDPR and Data Protection Act 2018 – confidentiality and lawful processing in incident management (ICO guidance currently under review following the Data (Use and Access) Act 2025).
• CQC Single Assessment Framework (SAF) – particularly the ‘Safe – Learning culture’ quality statement.

4. Definitions

• Notifiable safety incident (Regulation 20): For non-NHS providers, an unintended or unexpected incident occurring during a regulated activity that, in the reasonable opinion of a healthcare professional, appears to have resulted in or requires treatment to prevent: death; an impairment of sensory, motor or intellectual functions lasting ≥28 days; changes to body structure; prolonged pain or prolonged psychological harm; or shorter life expectancy. Near misses are not in scope for notifiable safety incidents.
• CQC statutory notification (Registration Regs): Incidents that must be notified to CQC without delay, including death of a person using the service (Reg 16) and, under Reg 18, serious injury, abuse or allegations of abuse, incidents reported to or investigated by the police, and events that stop a service running safely and properly.
• RIDDOR reportable incident: Events that meet HSE thresholds (e.g., death, specified injuries, over-7-day incapacitation, certain dangerous occurrences, occupational diseases, and non-worker injuries where taken directly to hospital for treatment).

5. Reporting and Documentation Procedures

To ensure accountability and transparency, all accidents, incidents, and near misses must be:

• Reported immediately to a supervisor, manager, or designated safety officer.
• Recorded in the Incident Report Log with details including date, time, location, individuals involved, and nature of the event.
• Escalated to external authorities (e.g., RIDDOR, CQC) if required by law.
• Reviewed within 24 hours to determine further action.

External notifications and time limits:

• Notify CQC without delay using the current statutory notification forms or Provider Portal when applicable: death (Reg 16); serious injury, abuse/allegations of abuse, police-related incidents, and events that stop the service running safely and properly (Reg 18).
• RIDDOR to HSE:
  • Submit reports online (telephone available only for fatalities/specified injuries).
  • Within 10 days for most reportable accidents; within 15 days for over-7-day incapacitation cases; without delay for deaths/specified injuries.
  • Members of the public: report if injured due to work activity and taken directly to hospital for treatment.
• Safeguarding: Where criteria in Care Act 2014, Section 42 are met, raise a safeguarding concern with the local authority (and police where a crime is suspected).
• Records: Keep RIDDOR records for at least 3 years (retain longer if local policy or litigation risk requires).

6. Investigation and Root Cause Analysis

Every reported event undergoes an immediate risk assessment and investigation, following these steps:

• Step 1: Gather Information
  • Collect witness statements and photographic evidence (if appropriate).
  • Interview affected individuals to understand the context.
• Step 2: Analyse Causes
  • Identify direct and underlying causes of the event.
  • Determine whether failure of equipment, human error, or environmental factors contributed.
• Step 3: Implement Corrective Actions
  • Immediate control measures to prevent recurrence.
  • Long-term improvements such as staff training or policy revisions.
• Step 3a: Duty of candour (Reg 20):
  • When an event meets the notifiable safety incident threshold, the relevant person is told as soon as reasonably practicable, an apology is given, facts known at the time are shared, and written records and updates (including actions to prevent recurrence) are provided and kept. Document all candour communications in the incident file.
• Step 4: Documentation and Review
  • Maintain records for compliance audits and safety improvements.
  • Share findings with staff to enhance safety awareness.

7. Preventative and Corrective Actions

To reduce the likelihood of recurrence, preventative actions include:

• Staff training on safety protocols and risk awareness.
• Regular risk assessments and safety audits in domiciliary settings.
• Equipment maintenance and safety checks for assistive devices.
• Encouraging open reporting culture to identify potential hazards before they escalate.
• Embed a learning culture consistent with the CQC Single Assessment Framework: systematically analyse events, share lessons with staff and people using services, and evidence resulting changes.
• Periodically verify equipment, environment and staffing controls align with Regulation 12 (Safe care and treatment) risk requirements.

Corrective actions following an incident may involve:

• Policy or procedural changes to enhance workplace safety.
• Environmental modifications (e.g., improved lighting, slip-resistant flooring).
• Additional supervision or refresher training for staff.

8. Staff Training and Responsibilities

All employees are required to:

• Attend mandatory health and safety training covering accident prevention and response.
• Understand their role in incident reporting and documentation.
• Follow emergency protocols and cooperate with investigations.
• Participate in post-incident debriefings and feedback sessions.

The Registered Manager is responsible for:

• Ensuring statutory notifications to CQC (Regs 16 and 18) are submitted without delay using current forms/portal.
• Ensuring RIDDOR reports are made to HSE within required time limits and that RIDDOR records are retained ≥3 years.
• Overseeing application of the duty of candour (Reg 20) when thresholds are met and assuring evidence of apologies, written records and learning.
• Coordinating safeguarding referrals to the local authority (Care Act s42).

9. Compliance Monitoring and Continuous Improvement

To maintain high safety standards, {{org_field_name}}:

• Conducts quarterly reviews of incident reports to identify trends and areas for improvement.
• Implements corrective measures based on investigation findings.
• Engages with staff and service users for safety feedback and improvement suggestions.
• Regularly updates this policy in response to regulatory changes and best practices.

We benchmark incident management against the CQC Single Assessment Framework ‘Safe – Learning culture’ quality statement and track actions through our governance cycle.

10. Policy Review and Updates

This policy is reviewed annually or sooner if:

• New legislation or regulations require amendments.
• Incident data suggests policy improvements are needed.
• CQC or HSE audits recommend changes to current practices.

This policy will also be updated when CQC updates statutory notification guidance/forms or when data protection guidance changes (e.g., ICO updates following the Data (Use and Access) Act 2025).

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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