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Registration Number: {{org_field_registration_no}}

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Notification of Other Incidents Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} identifies, responds to, records and reports notifiable “other incidents” and related statutory notifications in line with current legal and regulatory requirements for care homes in England.

This policy supports safe, well-led care by ensuring that incidents are:

• responded to promptly and appropriately;
• escalated to the right internal leads; and
• notified to the Care Quality Commission (CQC) and other relevant bodies without delay where required.

This policy also supports transparency with people who use the service and their representatives, and organisational learning to reduce the risk of recurrence.

2. Scope

This policy applies to:

• All employees (including full-time, part-time, bank, agency, and temporary staff).
• Volunteers, contractors and visitors where their actions/behaviour may relate to an incident.
• All regulated activities delivered by {{org_field_name}}.

This policy covers incidents involving:

• people we support (residents),
• staff,
• visitors and external professionals,
• the environment, premises, equipment and service continuity.

3. Legal and Regulatory Framework

This policy supports compliance with (non-exhaustive):

• Health and Social Care Act 2008 and the CQC regulatory framework.
• Care Quality Commission (Registration) Regulations 2009 – Regulation 18: Notification of other incidents.
• Care Quality Commission (Registration) Regulations 2009 – Regulations 14–18 and Regulation 22A (Form of notifications to the Commission), including statutory notifications relating to deaths, unauthorised absences, police involvement, serious injury, abuse/allegations of abuse, events affecting service continuity, and DoLS notifications/outcomes.
• Mental Capacity Act 2005 (and Deprivation of Liberty Safeguards, Schedule A1) – where DoLS notifications/applications and outcomes are relevant to CQC notifications.
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended), including Fundamental Standards relevant to safe care, safeguarding, staffing, and governance.
• Duty of Candour requirements (where applicable).
• Care Act 2014 safeguarding duties and local multi-agency safeguarding arrangements.
• Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) (where applicable).
• UK GDPR and Data Protection Act 2018 (lawful information sharing and record keeping).

4. Definitions

Incident: Any event that has caused or could cause harm, distress, abuse/neglect, loss, damage, disruption, or risk to residents, staff, visitors, or the safe running of the service.

Notifiable other incident: An incident that must be notified to CQC under Regulation 18 (and/or other CQC statutory notification categories) in accordance with CQC requirements.

Without delay: As soon as is reasonably practicable once the incident is recognised and enough initial information is available to make a meaningful notification. Updates must be provided where new material information arises.

Registered person: The registered provider and/or registered manager. Responsibility for notifications remains with the registered person even where tasks are delegated.

Safeguarding concern: Any concern that a resident (adult at risk) may be experiencing or at risk of abuse or neglect.

5. Policy Statement

{{org_field_name}} is committed to maintaining safe systems for:

• immediate response and escalation of incidents;
• accurate recording and investigation;
• prompt statutory notifications; and
• learning and quality improvement.

We will:

• prioritise safety, clinical support and safeguarding actions;
• act in an open and honest way with residents and their representatives;
• notify CQC and other agencies when legally required; and
• maintain records that demonstrate compliance and learning.

6. Roles and Responsibilities

6.1 All staff

All staff must:

• take immediate action to keep people safe and seek urgent medical help when required;
• report incidents immediately to the senior on duty/manager;
• preserve evidence where appropriate (e.g., equipment, records, CCTV requests) and lawful;
• complete incident documentation promptly and accurately.

6.2 Senior on duty / Shift lead

The senior on duty must:

• ensure immediate actions are taken (first aid, emergency services, medical review, safeguarding controls);
• ensure incident records are started promptly and key facts are captured;
• escalate to the Registered Manager (or on-call) without delay for potentially notifiable incidents.

6.3 Registered Manager ({{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}})

The Registered Manager (or delegated on-call manager) must:

• decide whether incidents meet the criteria for CQC notifications and other statutory reporting;
• ensure notifications are submitted without delay and updated as required;
• ensure safeguarding actions are taken and referrals made where necessary;
• ensure investigations, learning, and corrective actions are completed and monitored.

6.4 Nominated Individual  ({{org_field_nominated_individual_first_name}} {{org_field_nominated_individual_last_name}})

The Nominated Individual / Provider must:

• provide oversight of compliance, governance and resources;
• review trends and serious incidents; and
• ensure regulatory engagement is effective.

6.5 Safeguarding Lead ({{org_field_safeguarding_lead_name}})

The Safeguarding Lead will:

• advise on safeguarding thresholds and actions;
• support referrals and multi-agency working; and
• support learning and improvement.

6.6 Data Protection Officer (DPO) ({{org_field_data_protection_officer_first_name}} {{org_field_data_protection_officer_last_name}})

The DPO will:

• advise on lawful information sharing and minimisation;
• support secure handling of personal/special category data; and
• support retention and access control.

7. What must be notified

7.1 CQC – “Other incidents” (Regulation 18)

The Registered Manager (or delegated on-call manager) must ensure CQC is notified without delay of any incident that falls within Regulation 18, including:

• A serious injury to a person using the service that, in the reasonable opinion of a registered health care professional, results in permanent (or likely >28 days) impairment/structural change, prolonged pain or psychological harm, or reduced life expectancy; or requires treatment to prevent death or one of those outcomes.
• Any abuse or allegation of abuse relating to a person using the service (including neglect/acts of omission, and misuse/misappropriation of money or property).
• Any incident reported to, or investigated by, the police (whether or not a crime is confirmed at that stage).
• Any event that prevents, or is likely to threaten to prevent, the service running safely or in line with registration requirements, including (but not limited to): unsafe staffing levels; utilities interruption lasting more than 24 hours; significant premises damage affecting care; or fire alarm/safety device failure lasting more than 24 hours.
• Where applicable to the service type: placement of a person under 18 in an adult psychiatric unit for longer than 48 continuous hours.
• DoLS/MCA notifications required under Regulation 18, including requests/applications and notification of the outcome/withdrawal once known.

7.2 Other CQC statutory notifications (where applicable)

In addition to Regulation 18, the Registered Manager must ensure CQC is notified without delay where any other statutory notification category applies to the service, including (as relevant):

• Death of a person using the service.
• Unauthorised absence (and other absence notifications where applicable).
• Death of a detained mental health patient / MHA-related notifications (only where relevant to the service and legal status).
• Events that stop a service running safely and properly (where notified as a CQC notification category).
• Outcome of an application to deprive a person of their liberty (DoLS).
• Police involvement in an incident (where notified as a CQC notification category).

The Registered Manager must use the CQC “Notifications” list to confirm the correct category and submission route for each event and retain evidence of submission.

7.3 Other bodies (as applicable)

Depending on the incident, we may also need to notify:

• Local Authority (Adult Safeguarding) – where abuse/neglect is suspected or alleged.
• Police – where a crime is suspected or immediate danger exists (999 / 101 as appropriate).
• HSE (RIDDOR) – where a reportable work-related incident occurs.
• UKHSA / local Health Protection Team – for suspected outbreaks/serious infection control incidents in line with local arrangements and guidance.
• Commissioners / placing authorities – per contract and safeguarding requirements.
• Fire & Rescue Service / enforcing authorities – where relevant.

8. Procedure for notifying CQC

8.1 Immediate actions before notification

Before (or alongside) notifying CQC, we will ensure:

• the person is safe and has appropriate medical attention;
• safeguarding measures are in place;
• the incident is recorded and key facts gathered;
• the Registered Manager/on-call is informed promptly.

8.2 How notifications are made

Notifications must be submitted using the current CQC method for that notification type. Where available, we will submit via the CQC Provider Portal. Where the portal does not support the notification type, we will use the latest CQC notification form and submit it by the required method (currently, CQC states that notifications not available in the portal must continue to be submitted by email: HSCA_notifications@cqc.org.uk). Evidence of submission (confirmation email / portal receipt) must be saved in the incident record.

8.3 Timescales

• Notifiable incidents must be notified without delay.
• If all details are not yet known, an initial notification will be submitted and updated when material information becomes available.

8.4 Information to include (as appropriate)

Notifications should include:

• service/provider details and location;
• date/time and place of incident;
• factual summary of what happened (avoid speculation);
• who was involved (only necessary personal data);
• immediate actions taken (clinical response, safeguarding, service controls);
• agencies informed (safeguarding, police, HSE, UKHSA, commissioner);
• ongoing risks and mitigation measures.

9. Safeguarding referrals and local authority contacts

Where a safeguarding concern is identified, staff must escalate immediately and a referral/concern will be raised without delay in line with local arrangements.

10. Recording, investigation and learning

All incidents must be recorded in the organisation’s incident reporting system and include:

• what happened, when/where, who was involved;
• immediate actions taken;
• witnesses and evidence preserved (where applicable);
• outcomes and follow-up actions.

The Registered Manager will ensure:

• proportionate investigation is completed (including root cause analysis for serious incidents);
• action plans are created, assigned and tracked to completion;
• learning is shared with staff and embedded into practice (training, supervision, audits, care planning, risk assessments).

11. Confidentiality and data protection

We will share information:

• lawfully, fairly and transparently;
• on a need-to-know basis;
• using data minimisation (only necessary information);
• securely (access controls, secure transfer, appropriate redaction).

Where notifications contain personal/special category data, we will ensure the rationale and legal basis is documented.

12. Training and awareness

All staff will receive training and guidance appropriate to their role, including:

• recognising and responding to incidents;
• safeguarding and escalation pathways;
• accurate record keeping;
• understanding when a CQC notification may be required;
• confidentiality and information governance.

Refresher training will be provided at least annually, and sooner if learning from incidents identifies a need.

13. Monitoring, audit and review

The Registered Manager will monitor:

• the quality and timeliness of incident recording and notifications;
• completion of investigations and action plans;
• incident trends and themes, and any required improvements.

This policy will be reviewed:

• annually, or sooner if legislation, CQC requirements, or significant incidents indicate the need for change.

Appendix  – CQC statutory notifications quick reference

The Registered Manager must maintain and use a current quick reference list of CQC statutory notification categories relevant to the service, aligned to the CQC “Notifications” webpage and Regulations 14–18 and 22A. This appendix must be reviewed whenever CQC updates notification routes (e.g., portal availability) and at least annually.

The quick reference must state for each notification category: the trigger/threshold, the required timescale (“without delay”), the submission route (provider portal vs email form), who completes it, and where evidence is stored.

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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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