{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

Notification of Other Incidents Policy

1. Introduction and Purpose

This policy defines how {{org_field_name}} will handle reporting of incidents affecting the health, safety, or welfare of service users. Care homes are required by CQC Regulation 18 to notify the Commission of certain serious incidents, but we also record and review other relevant events internally to improve safety. Under Reg 18, providers must report “all incidents that affect the health, safety and welfare of people who use services” without delay. Failure to do so is a legal offence. This policy ensures that staff understand which events require formal notification (both to CQC and to other agencies or individuals) and how to report them promptly.

2. Scope

This policy applies to all CQC-regulated activities provided by {{org_field_name}}, including residential and nursing care. It covers both the statutory notifications required by Regulation 18 of the CQC (Registration) Regulations 2009 and additional incident reporting procedures. All employees, volunteers, agency staff, and contractors working in our services must comply with this policy. The Registered Manager of {{org_field_name}} has lead responsibility for overseeing incident reporting and ensuring compliance with this policy.

Statutory Notifiable Incidents (Regulation 18)

Under Regulation 18, certain serious incidents must be reported directly to CQC. The main categories include:

• Serious injuries to a service user: Any injury that in the reasonable opinion of a healthcare professional results in permanent or long-term impairment of the person’s sensory, motor, or intellectual functions; changes to body structure; prolonged pain or psychological harm; or a shortening of life expectancy. This also covers injuries requiring medical or healthcare treatment to prevent death or serious harm. (Examples: major fractures, organ damage, serious burns, grade 3/4 pressure ulcers developed in care, etc.)
• Abuse or allegations of abuse of a service user: Any incident of suspected or confirmed abuse (physical, sexual, emotional, financial, discriminatory, or neglect) involving a service user. This includes allegations against staff, other residents, or visitors. Even unproven or suspected abuse must be notified to CQC. (Safeguarding authorities and the police are also notified under our Safeguarding Policy.)
• Incidents reported to or investigated by the police: Any event in which the police are called in relation to our service. For example, if a resident goes missing (usually prompting police involvement), if there is an assault, theft, or any suspected crime on-site.
• Major service disruptions: Any event that prevents, or is likely to prevent, the safe delivery of care or compliance with our registration. This includes, for example, having too few qualified staff to meet residents’ needs, prolonged loss of utilities (water, gas, electricity, sewerage) for over 24 hours, significant damage to the building (e.g. by fire or flood) affecting care, or failure of critical safety systems (fire alarms, call bells) lasting longer than 24 hours.
• Other statutory notifications: (For completeness, though covered under separate policies: deaths of service users, incidents involving detained patients under the Mental Health Act, or outcomes of DoLS/LPS applications must also be notified to CQC per other regulations.)

Note: If staff are unsure whether an incident fits these criteria, they should err on the side of caution and notify the Registered Manager immediately. The Registered Manager will determine CQC notifiability. (CQC can prosecute providers for failing to make a required notification.)

Other Reportable Incidents (Internal Reporting)

In addition to the above, {{org_field_name}} requires all staff to record and report certain non-statutory incidents and near misses for internal learning and safeguarding. These include, but are not limited to:

• Minor injuries or incidents: Any injury to a resident that does not meet the Reg 18 definition (for example bruises, sprains, minor cuts, falls not causing serious harm). Even if no external notification is needed, these should be logged on an internal incident form.
• Near misses: Events that could have led to harm but did not (for example, a resident nearly tripping but catching themselves, a medication error discovered before administration). Although no injury occurred, staff must report near misses so we can analyse and prevent future accidents. (CQC guidance notes that reviewing near misses provides valuable learning.)
• Challenging or behavioural incidents: Aggressive or challenging behavior by residents (towards staff or other residents), self-harm attempts that did not result in serious injury, property damage by residents, or other behavioural events that require staff intervention. While not all such incidents trigger a CQC notification, they must be recorded and reviewed internally.
• Medication-related events: All medication errors or discrepancies, whether or not they cause harm, must be reported. This includes wrong dosage, wrong resident, omitted doses, or any incident of self-medication. Our medicines management process requires robust reporting of all medicine incidents and near misses (even though CQC need only be notified if an error causes serious harm).
• Other health/safety incidents: Minor infections or outbreaks (e.g. a few cases of vomiting/diarrhoea), minor burns or choking incidents resolved on-site, trips, slips, or falls without injury, needlestick injuries, etc. All such events should be entered into the accident/incident log for monitoring. Similarly, any accident or injury to staff or visitors on duty should be reported for health-and-safety purposes.
• Safeguarding concerns: Any suspicion or concern (even if no harm has occurred yet) about abuse or neglect of a resident. While confirmed abuse is reported to CQC (Reg 18), any safeguarding alerts or concerns must be raised immediately through our Safeguarding Adults procedures. This includes notifying the local authority safeguarding team or police as appropriate.
• Duty of Candour communications: Whenever an incident harms a resident or could cause reasonably foreseeable harm, staff should inform the resident (or their family) in line with our Duty of Candour obligations. For example, if an error or accident occurs, staff must tell the person and/or their family what happened as soon as possible, provide an apology, and follow up in writing.
• Other relevant events: Any other incidents that may impact care quality or safety, such as fire alarms, security breaches, or equipment failures not captured above. These should be reported and recorded so that corrective actions can be taken promptly.

These additional reports are part of our internal risk management. They may prompt investigations or changes to practice even if they do not meet CQC’s “notifiable” threshold. For each such incident, staff must notify their line manager or the Registered Manager immediately and complete the standard incident form. This ensures timely review and action.

Internal Reporting and Escalation Procedures

1. Immediate Action: When any incident occurs, staff must first ensure safety. This may involve administering first aid, calling emergency services, or taking steps to secure the environment. Staff should also reassure residents and protect evidence of the incident if needed.
2. Notification to Management: Staff must report the incident to the Registered Manager or senior person on duty without delay.

How to report:

Send an email detailing the concern to the Registered Manager at: {{org_field_registered_manager_email}}.

Call the office to inform the Registered Manager at {{org_field_phone_no}}.

If the concern arises out of office hours, call the out-of-hours phone number: {{out_of_hours}}.

Website: {{org_field_website}} – using the contact form provided

Even if it is unclear whether the event is notifiable to CQC, it should be reported internally. Staff must document the incident in our internal reporting system (or incident book) promptly, including details of what happened, who was involved, and initial actions taken.

3. Information Gathering: The Registered Manager (or delegated person) will gather all relevant information: witness statements, clinical notes, photographs (if appropriate), etc. They will assess whether the incident meets any statutory notification criteria.
4. Duty of Candour: If the incident has harmed (or could harm) a service user, the Manager must ensure the resident (and/or their family or representative) is informed in a sensitive and timely way, offering an apology and explanation as required by Reg 20 (Duty of Candour). Documentation of these conversations is kept on file.
5. Determine Notifications: The Manager decides which external notifications are required. All Reg 18 incidents are reported to CQC via the online portal. In addition:
   • Families/Representatives: Inform family or advocate of any significant incidents or injuries per our communication protocol.
   • Safeguarding Authorities: If the incident involves abuse or suspicion of abuse, the Manager must make a safeguarding referral to the local authority immediately, in line with our Safeguarding Policy.
   • Emergency Services/Police: If not already involved, staff should summon police or ambulance as needed. Incidents already reported to police (e.g. theft, assault) are also notified to CQC (Reg 18).
   • Other Agencies: Report to any other body required by law (e.g. notify Health & Safety Executive if a staff RIDDOR event, Public Health England/Environmental Health for a disease outbreak, etc.).
6. Submission to CQC: For all Reg 18 notifications, the Registered Manager (or delegate) must complete the CQC notification form online without delay. The incident description should be factual and include dates, people involved, and actions taken. If the incident involves death or serious injury, the Manager should also record how the Duty of Candour was complied with (e.g. resident/family informed).
7. Follow-up and Learning: After the incident, the Manager will review what happened and identify any lessons. This may involve updating risk assessments, care plans, or policies. Learning should be shared with staff (e.g. in team meetings) to prevent recurrence.

3. Roles and Responsibilities

• Registered Manager: Has overall responsibility for ensuring this policy is implemented. They must ensure all required notifications are made promptly and accurately. The Manager will train staff on this policy and oversee incident investigations. The Manager (or deputy) is the person authorised to submit official notifications to CQC.
• Deputy/On-Call Manager: In the Manager’s absence, the deputy or on-call manager takes charge of incident management and notifications. They must be familiar with this policy and the CQC portal.
• All Staff: Everyone working at {{org_field_name}} (care staff, nursing staff, administration, maintenance, etc.) must report any accident, injury, abuse concern, or unusual event immediately to their manager. Staff are responsible for recording incidents accurately and cooperating in any investigation. They must understand that even near misses or minor injuries should be reported so we can improve safety. Staff should not be afraid of reporting errors or problems – our culture supports learning and transparency.
• Registered Person/Provider: The organisation ({{org_field_name}}) holds ultimate accountability for compliance with legal notification duties. The Responsible Individual or company directors must ensure resources and support for this policy and may review incident trends for governance purposes.

4. Training and Awareness

All staff will receive training on this policy during induction and annual refresher training. Training will cover identifying incidents, reporting procedures (internal forms, CQC portal), and legal obligations (Reg 18 notifications and Duty of Candour). Management will provide examples of reportable events so staff can recognize them. Staff will be reminded that reviewing all safety incidents and near misses is part of our duty to improve care.

5. Monitoring and Review

Incident logs and notification records will be reviewed regularly by management and the Quality team. We will audit timeliness and completeness of statutory notifications to CQC. This policy will be reviewed at least annually or after any major incident to ensure it remains up to date with legislation and best practice.

Sources: This policy reflects CQC regulations and guidance and relevant NHS/NICE guidance on incident reporting and duty of candour.

---

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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.