CHW25-Notification of Other Incidents Policy

Registration Number: {{org_field_registration_no}}

Notification of Other Incidents Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} complies with the Regulation and Inspection of Social Care (Wales) Act 2016 and the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, which require care providers to report specific incidents to Care Inspectorate Wales (CIW), relevant authorities, and key stakeholders. This policy ensures that all notifiable incidents are promptly recorded, investigated, and reported, maintaining transparency and safeguarding the well-being of residents and staff.

2. Scope

This policy applies to:

All staff members, including care staff, management, support staff, and contractors.
Residents and their families, ensuring that they are informed of relevant incidents.
External agencies, including CIW, local authorities, emergency services, and public health bodies.
The Registered Manager and Responsible Individual, who are responsible for ensuring compliance with incident notification regulations.

3. Compliance with CIW Regulations and Legal Framework

This policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016 and the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (as amended), including:

Regulation 60 and Schedule 3 (Notifications by the service provider): requiring the service provider to notify CIW of events listed in Parts 1 and 2 of Schedule 3. Notifications must include details of the event and, unless otherwise stated, must be made without delay and in writing, in the manner and form required by CIW (for example, via CIW Online).
Regulation 59 (Records) and Regulation 78 (Systems for record keeping): requiring accurate, complete and secure records and effective systems to support oversight and audit.
Social Services and Well-being (Wales) Act 2014: safeguarding duties, including making referrals where required.
Health and Safety at Work etc. Act 1974 and RIDDOR 2013: reporting relevant workplace incidents to the appropriate authority.

This policy should be read alongside our Safeguarding, Whistleblowing, Complaints, and Duty of Candour / Open and Transparent Practice arrangements (including Responsible Individual duties).

4. Types of Notifiable Incidents

For CIW purposes, “notifiable incidents” under this policy are the events listed in Schedule 3 (Parts 1 and 2) of the 2017 Regulations. Where this policy uses plain-English examples (e.g., “serious accident”), staff must check whether the event meets the Schedule 3 category and any applicable threshold/definition.

{{org_field_name}} ensures that the following incidents are reported in accordance with CIW guidelines:

Serious Injury or Death of a Resident or Staff Member
Allegations or Suspicions of Abuse
Outbreak of an Infectious Disease (e.g., COVID-19, Norovirus, Flu)
Serious Medication Errors
Absence Without Authorisation (Missing Resident)
Serious Accidents or Injuries (Falls, fractures, burns, head injuries, hospitalisations)
Fire or Major Property Damage
Significant Staffing Shortages Impacting Care
Security Breaches or Intrusions
Safeguarding Concerns Requiring Police or Local Authority Involvement

Accident/Injury notification threshold (Schedule 3)

We will notify CIW of any accident or injury to an individual which, in the reasonable opinion of a health care professional, requires treatment by that (or another) health care professional and has or may have resulted in:

damage or impairment (permanent or likely to last more than 28 days) of sensory, motor or intellectual functions; or
changes to the structure of the body; or
prolonged pain or prolonged psychological harm; or
death or shortening of life expectancy.

5. Incident Reporting Procedures

5.1 Immediate Response and Containment

Ensure Safety First: Staff must prioritise the safety and well-being of all individuals affected.
Seek Medical Assistance: If required, emergency services should be contacted immediately.
Isolate the Incident: If an environmental hazard is involved (e.g., fire, chemical spill), the area should be secured.

5.2 Recording the Incident

Complete an Incident Report Form: All incidents must be recorded in detail, including time, location, individuals involved, actions taken, and witnesses.
Notify the Registered Manager: The Registered Manager must be informed immediately to assess the severity of the incident.
Gather Evidence: Where appropriate, photos, CCTV footage, and witness statements should be collected.

Incident records must be accurate, complete, signed/dated (or electronically authenticated), and stored securely. Where records are electronic, access must be controlled and the system must provide an audit trail showing who created/edited entries and when.

The incident record must include (where applicable) the CIW Online notification submission date/time and reference, safeguarding referral reference, police incident number, key decisions made, outcomes, and closure notes.

5.3 Notifying Relevant Authorities

CIW Notification (Regulation 60 / Schedule 3): Where the event meets the Schedule 3 notification criteria, the Registered Manager (or designated CIW Online assistant) must submit the notification via CIW Online, without delay (usually within 24 hours of the event occurring), including the known facts at the time and actions taken to safeguard individuals.

If information is incomplete at the time of the initial notification, we will submit the initial notification without delay and provide an update via CIW Online as soon as further verified information becomes available (e.g., outcome of medical assessment, safeguarding strategy discussion/outcome, police incident number, internal investigation findings, or learning/actions taken).

Safeguarding Authorities: If abuse or neglect is suspected, the Local Authority Safeguarding Team must be contacted immediately.
Public Health Wales: For infectious disease outbreaks, the Local Health Protection Team must be notified.
HSE (Health and Safety Executive): For workplace injuries meeting RIDDOR criteria, HSE must be informed.
Family Notification: The resident’s next of kin must be informed in line with the resident’s consent and confidentiality policies.

5.4 Roles, delegation, and governance oversight

Registered Manager: Responsible for deciding whether an event meets Schedule 3 criteria, ensuring immediate safeguarding actions are taken, and ensuring notifications are submitted without delay.

Responsible Individual (RI): Ensures suitable arrangements are in place so notifications are made correctly and learning is embedded through governance processes.

CIW Online access/delegation: Where appropriate, the RI/Provider may authorise a member of staff as a designated CIW Online assistant to submit notifications on behalf of the service. Authorisation and access levels must be reviewed at least annually and immediately on role change or termination.

Governance: All CIW notifications and outcomes (including safeguarding/complaints/whistleblowing themes) will be reviewed through governance arrangements to identify patterns, risks, and service improvements.

6. Monitoring and Investigation of Incidents

Internal Investigation: The Registered Manager must lead an investigation, reviewing contributing factors and root causes.
Corrective Actions: Any failures or procedural weaknesses must be addressed through updated training, policies, or corrective measures.
Lessons Learned Meetings: Staff are debriefed on incidents to prevent future occurrences.
Trend Analysis: Incident trends are reviewed quarterly to identify recurring issues and implement strategic improvements.

7. Training and Staff Responsibilities

All staff receive training on incident reporting procedures and regulatory requirements during induction and through annual refresher courses.
Managers and senior staff are trained in root cause analysis and risk mitigation to improve incident response.
Staff accountability is reinforced through supervision and audits, ensuring timely and accurate reporting of incidents.

8. Continuous Improvement and Compliance

To maintain high standards of safety and regulatory compliance, {{org_field_name}} implements:

Regular audits of incident records to verify accuracy and completeness.
Annual reviews of this policy to reflect legislative updates and best practices.
Resident and staff feedback mechanisms to identify potential risks and areas for improvement.
Collaboration with CIW and external agencies to enhance safeguarding and risk management.

9. Related Policies

This policy should be read alongside:

CHW11 – Safe Care and Treatment Policy
CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
CHW16 – Health and Safety at Work Policy
CHW18 – Risk Management and Assessment Policy
CHW24 – Management of Accidents, Incidents, and Near Misses Policy

10. Policy Review

This policy will be reviewed annually or sooner if regulatory changes occur or following a significant incident requiring procedural updates. The Registered Manager and Responsible Individual will oversee compliance and effectiveness.

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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