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Management of Accidents, Incidents, and Near Misses Policy

1. Purpose

The purpose of this policy is to ensure that all accidents, incidents, and near misses are managed effectively, transparently, and in compliance with CIW regulations. This policy ensures that:

• Service users, staff, and visitors are protected from harm through proactive risk management.
• Accidents and incidents are reported, investigated, and recorded accurately.
• Preventative measures are taken to reduce recurrence.
• Legal and regulatory requirements are met, including The Regulation and Inspection of Social Care (Wales) Act 2016 and The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017​.

2. Scope

This policy applies to:

• All staff members, including care staff, maintenance teams, and administrative staff.
• Registered Manager and Responsible Individual, ensuring compliance with CIW regulations.
• Service users and their families, ensuring they are informed and involved in incident resolution.
• External agencies, including Care Inspectorate Wales (CIW), health professionals, and emergency services where required.

3. Related Policies

This policy should be read in conjunction with:

• Safe Care and Treatment Policy (CHW11)
• Health and Safety at Work Policy (CHW16)
• Risk Management and Assessment Policy (CHW18)
• Emergency and Business Continuity Plan (CHW19)
• Fire Safety and Evacuation Procedures (CHW20)
• Safeguarding Adults from Abuse and Improper Treatment Policy (CHW13)
• Notification of Other Incidents Policy (CHW25)
• Duty of Candour Policy (CHW35)​.

4. Policy Statement

{{org_field_name}} is committed to ensuring a safe environment for all service users, staff, and visitors. A proactive and systematic approach is in place to manage all accidents, incidents, and near misses, ensuring lessons are learned and improvements are made.

The policy follows a no-blame culture, encouraging staff to report incidents without fear of repercussions, focusing on continuous improvement and risk prevention.

5. Implementation and Management

5.1 Governance and Leadership

• The Responsible Individual (RI) has overall accountability for ensuring compliance with CIW regulations​.
• The Registered Manager oversees the incident reporting process, investigations, and corrective actions.
• A Health and Safety Lead is responsible for ensuring risk assessments are conducted and reviewed following incidents.

5.2 Definitions of Accidents, Incidents, and Near Misses

• Accident: Any unexpected event that results in harm or injury to a service user, staff member, or visitor.
• Incident: An event that causes or has the potential to cause harm, such as medication errors, falls, or security breaches.
• Near Miss: An event that could have led to harm but was prevented before any injury or damage occurred.

5.3 Incident Reporting Procedure

1. Immediate Response and First Aid
   • Staff must immediately assess the situation and provide first aid as necessary.
   • If required, emergency services are contacted, and families or next of kin are informed.

Where the incident indicates something has gone wrong in the service, staff must also follow the Duty of Candour Policy (CHW35): communicate openly and honestly, offer an apology where appropriate, and provide information about the incident and the outcomes of any investigation.

2. Incident Documentation
   • The staff member involved must complete an Incident Report Form immediately after the event.
   • Reports should include:
     • Date, time, and location of the incident.
     • Names of individuals involved.
     • Description of what happened.
     • Actions taken immediately (first aid, security measures, etc.).
     • Witness statements if applicable.

The incident record must also include (where applicable): body maps and/or photographs (where appropriate and in line with consent/lawful basis), clinical advice received, immediate risk controls implemented, whether the incident meets CIW Schedule 3 and/or Schedule 4 notification criteria, who was notified (e.g., CIW, Local Authority safeguarding, police, Public Health Wales), the date/time and method of notification (including CIW Online submission), investigation outcome, learning actions and any changes to care plans/risk assessments. Copies of all external notifications and reference numbers must be stored with the incident record.

3. Investigation and Root Cause Analysis
   • All incidents are investigated by the Registered Manager or appointed investigator.
   • Root cause analysis (RCA) is conducted for serious incidents to identify contributing factors.
   • Findings are documented, and corrective actions are implemented.
4. Notification to CIW and Other Authorities
   • Where an event meets the CIW notification requirements, the Service Provider/Registered Manager must ensure a notification is submitted to CIW without delay and in writing, using CIW Online, and the notification must include sufficient details of the event, immediate actions taken and current risk controls. Notifications must be made in the manner and form required by CIW (CIW Online).
   • Other agencies such as local safeguarding teams, police, or public health authorities may also be notified where appropriate.

5.3.1. CIW notifiable events (Schedule 3) – care home services

The Registered Manager must check every accident, incident and near miss against the CIW notification requirements set out in Schedule 3 (Notifications by the service provider) of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017. Where the event is notifiable, CIW must be notified without delay and in writing, using CIW Online, and a copy of the notification must be retained on the incident file.

Notifiable events include (where applicable, and not limited to):

• Any allegation of abuse (including suspected, witnessed or alleged abuse) involving the service provider, staff, volunteers, or any other person on the premises, or affecting an individual using the service.
• Any allegation of misconduct by a member of staff.
• Any occurrence of category 3 or category 4 pressure damage, or unstageable pressure damage.
• Any serious accident or serious injury to an individual, including where, in the reasonable opinion of a healthcare professional, treatment is required and the injury has, or may have, resulted in:
  • long-term impairment (meaning lasting, or likely to last, more than 28 days),
  • prolonged pain or prolonged psychological harm, or
  • death or a shortened life expectancy.
• Any outbreak of infectious disease in the service.
• Any incident reported to the police (including where police involvement is requested or required).
• Any event which prevents, or could prevent, the service being provided safely, including (but not limited to):
  • unsafe staffing shortfalls,
  • interruption to essential utilities for more than 24 hours (e.g., water, heating, electricity), and/or
  • failure of key safety systems for more than 24 hours (e.g., fire alarm system).
• Where accommodation is provided: the death of an individual, and the circumstances of the death.
• Any request to a supervisory body relating to Deprivation of Liberty Safeguards (DoLS) (where applicable).

For each CIW notification, the incident record must clearly state: what happened, immediate actions taken, risk controls put in place, who was notified, and the date/time the CIW notification was submitted.

For avoidance of doubt, “events which prevent, or could prevent, the service being provided safely” include (but are not limited to) unsafe staffing shortfalls, loss of utilities for more than 24 hours, serious premises damage impacting the ability to provide care safely, or safety system failure (e.g., fire alarm) for more than 24 hours.

5.3.2. Responsible Individual notifications (Schedule 4)

The Responsible Individual (RI) has a separate legal duty to notify CIW of events listed in Schedule 4 (Notifications by the responsible individual) of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017.

To ensure compliance, the Registered Manager must inform the RI without delay of any incident, event or pattern of incidents that may trigger a Schedule 4 notification. The Registered Manager must provide the RI with sufficient information to support an accurate notification, including: a summary of what happened, immediate actions taken, safeguarding action (if any), any medical treatment provided, and any ongoing risk control measures.

5.3.3. RIDDOR (HSE reporting) – staff and visitor incidents

Where an accident or incident is work-related and meets the reporting criteria under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR), the Registered Manager (or a delegated competent person) must ensure the event is reported to the Health and Safety Executive (HSE) within the required timescales.

This includes (not exhaustive):

• work-related fatalities,
• specified injuries,
• injuries leading to over-7-day absence from work,
• reportable dangerous occurrences, and
• diagnosed reportable occupational diseases.

A record of the RIDDOR submission (including the reference number), investigation findings, and corrective actions must be retained with the incident documentation.

5.4 Managing Different Types of Incidents

Falls and Physical Injuries

• A falls risk assessment is conducted for all service users.
• Care plans are adjusted to incorporate fall prevention strategies.
• Post-fall monitoring ensures early detection of complications such as head injuries.

Medication Errors

• Errors must be reported immediately, even if no harm occurs.
• A pharmacist review is conducted, and training is provided to prevent recurrence​.

Safeguarding Incidents

• Any concerns about abuse or neglect are immediately reported to the Safeguarding Lead and local safeguarding authorities​.
• A confidential and supportive approach is taken to protect service users.

Infection Control Incidents

• Outbreaks of infectious diseases are reported to Public Health Wales.
• Enhanced infection control measures are implemented immediately​.

5.5 Learning from Incidents and Prevention Strategies

• Quarterly incident audits identify trends and areas for improvement.
• Findings from serious incidents are discussed in staff meetings to improve practice.
• Lessons learned are incorporated into policies, procedures, and staff training.

5.6 Staff Training and Competency

• All staff receive training on incident reporting, risk assessment, and emergency response.
• Refresher training is provided following significant incidents to address gaps in knowledge.
• Simulation exercises (e.g., fire drills, emergency response drills) ensure staff are prepared for real-life situations​.

5.7 Compliance Monitoring and Continuous Improvement

• The Registered Manager conducts monthly compliance checks to ensure reporting procedures are followed.
• Annual policy reviews ensure compliance with CIW standards and evolving best practices.
• Feedback from service users, families, and staff informs continuous improvements.

6. Compliance with Legislation and Regulations

This policy ensures compliance with:

• The Regulation and Inspection of Social Care (Wales) Act 2016​.
• The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017​.
• The Social Services and Well-being (Wales) Act 2014.
• Health and Safety at Work Act 1974.
• CIW standards on incident management and reporting​.

• Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).
• Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 – Schedule 3 and Schedule 4 notification requirements (CIW Online).
• Social Care Wales – Professional Duty of Candour guidance (where applicable) and organisational Duty of Candour arrangements.
• Data Protection Act 2018 and UK GDPR (incident records, information sharing and retention).

7. Policy Review

This policy will be reviewed annually or sooner if legislative requirements change. The Registered Manager is responsible for ensuring this policy remains current and effective.

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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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