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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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CIW Notifications Policy

1. Purpose

This policy sets out how {{org_field_name}} identifies, records, and notifies reportable events to Care Inspectorate Wales (CIW) and other relevant bodies in line with Welsh legislation. Our aim is to ensure that significant incidents affecting people who use our service (adults and children), their families, and our staff are reported promptly, transparently and accurately. The policy underpins our duty to protect wellbeing and rights, to learn from incidents, and to continuously improve the quality and safety of care.

This policy supports compliance with Regulation 60 and Schedule 3 of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, which require the service provider to notify the service regulator and, where applicable, other authorities of specified events. It also supports compliance with Regulation 84 and Schedule 4, which require the Responsible Individual to notify the service regulator of specified management-related events. Unless a different timescale is stated, notifications must be made without delay, in writing, and in the manner and form required by CIW.

2. Scope

This policy applies to all staff, the Registered Manager, the Responsible Individual, agency workers, and visiting professionals working with {{org_field_name}}. It covers:

• What constitutes a notifiable incident in Wales.
• Who must be informed (CIW, Local Authority, Police, Health Board/Public Health Wales, parents/carers where appropriate).
• Timeframes for notification.
• Roles and responsibilities at each stage.
• Recording, learning, and improvement following incidents.

Notifications to CIW must be submitted through CIW Online, unless CIW directs otherwise. The Responsible Individual may delegate an appropriate person working at the service to act as a CIW Online assistant, where this is permitted by CIW, but accountability for ensuring notifications are accurate, complete and submitted within the required timescale remains with the service provider and/or Responsible Individual as applicable.

3. Legal and Regulatory Framework (Wales)

Our practice is governed by:

• Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA)
• Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 – including duties to notify CIW of certain events and to ensure safe, effective service delivery
• Social Services and Well-being (Wales) Act 2014 (SSWBA) – including the duty to report adults or children at risk and to follow the Wales Safeguarding Procedures (2019)
• Children Act 1989 and 2004 (where children receive services)
• Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) (for people aged 16+)
• Public Health (Control of Disease) legislation and Public Health Wales guidance on notifiable diseases
• UK GDPR and the Data Protection Act 2018 (confidentiality, data minimisation and secure handling of incident information)

• The Regulated Services (Registration) (Wales) Regulations 2017, including requirements relating to the Statement of Purpose and registered service details.
• Regulation 60 and Schedule 3 of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended – notifications by the service provider.
• Regulation 84 and Schedule 4 of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended – notifications by the Responsible Individual.
• CIW Online notification requirements and any current CIW guidance on notifications, variations and online assistants.
• The Safeguarding Vulnerable Groups Act 2006, including the duty to make DBS referrals where the legal threshold is met.

4. What We Must Notify and to Whom

{{org_field_name}} will notify CIW and, where applicable, other relevant authorities of all events required under Regulation 60 and Schedule 3 of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended. Notifications must include sufficient details of the event, the immediate action taken, any continuing risk, any safeguarding or public protection action, and any further action planned.

4.1 Notifications to CIW for all care home services

The service provider must notify CIW of the following:

• Any revision to the Statement of Purpose, at least 28 days before the revised Statement of Purpose takes effect, unless the change must take effect immediately.
• Any change to the service provider’s name.
• Where the service provider is a body corporate, any change in directors, trustees or members of the managing committee.
• Where the service provider is an unincorporated body, any change in the persons concerned in the management and control of the body.
• Where the service provider is an individual, the appointment of a trustee in bankruptcy.
• Where the service provider is a body corporate or partnership, the appointment of a receiver, manager, liquidator or provisional liquidator.
• Where the service provider is a partnership, the death of a partner or any change in partners.
• The expected absence of the Responsible Individual for 28 days or more, at least 7 days before the absence begins.
• The unexpected absence of the Responsible Individual, no later than 7 days after the absence begins.
• The unexpected absence of the Responsible Individual for 28 days or more, where no prior notification has been made, immediately on the expiry of 28 days from the start of the absence.
• The return from absence of the Responsible Individual.
• The Responsible Individual ceasing, or proposing to cease, to be the Responsible Individual for the service.
• Any abuse or allegation of abuse in relation to an individual where the allegation involves the service provider, a member of staff or a volunteer.
• Any conviction of the service provider, Responsible Individual or appointed manager for a criminal offence.
• 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 injury to an individual.
• The outbreak of any infectious disease.
• Any incident reported to the police.
• Any event which prevents, or could prevent, the provider from continuing to provide the service safely.
• Where accommodation is provided, the death of an individual and the circumstances of the death.
• Any request to a supervisory body in relation to the application of the Deprivation of Liberty Safeguards.
• Any premises that are, or are proposed to be, significantly altered or extended.
• Any additional premises that are, or are proposed to be, acquired.
• Any proposal to change the address of the principal office, at least 28 days before the change takes place.

4.2 Serious accident or injury

For the purposes of notification, a serious accident or injury includes any accident or injury 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, either permanent or likely to last for more than 28 days, of the individual’s sensory, motor or intellectual functions;
• changes to the structure of the individual’s body;
• prolonged pain or prolonged psychological harm;
• death or shortening of the individual’s life expectancy.

4.3 Events which prevent or could prevent safe service delivery

Events which prevent, or could prevent, {{org_field_name}} from continuing to provide the service safely include, but are not limited to:

• insufficient numbers of suitably qualified, trained, skilled, competent and experienced staff;
• interruption to electricity, gas, water or sewerage supply lasting longer than 24 continuous hours;
• physical damage to the premises which has, or is likely to have, a detrimental effect on the care and support provided to individuals;
• failure or malfunction of the heating system lasting longer than 24 continuous hours;
• failure or malfunction of fire alarms or other safety devices lasting longer than 24 continuous hours;
• fire, flood, evacuation, cyber incident, major IT failure, infection outbreak, significant environmental risk or any other incident affecting the safe running of the service.

4.4 Safeguarding, abuse, misconduct and DBS referrals

Where there is any allegation or evidence of abuse, neglect, improper treatment, misconduct or harm, staff must take immediate action to protect individuals, report the matter internally, make safeguarding referrals in line with the Wales Safeguarding Procedures, preserve relevant evidence and ensure that CIW and other relevant bodies are notified as required. Where the legal threshold for a DBS referral is met, the referral must be made without delay and CIW must be notified where this is a notifiable event.

4.5 Deprivation of Liberty Safeguards

Any request made to a supervisory body in relation to the application of the Deprivation of Liberty Safeguards must be notified to CIW. This includes new requests and any further request where the person’s circumstances or authorisation status changes. The notification record must identify the date of the request, the person concerned, the reason for the request, the supervisory body contacted and any urgent authorisation or interim risk management arrangements in place.

4.6 Additional notifications where care and support is provided to children

Where {{org_field_name}} provides care and support to children, the service provider must also notify CIW of the following:

• Any referral to the DBS under the Safeguarding Vulnerable Groups Act 2006.
• Where the service provider, Responsible Individual or appointed manager is charged with a relevant safeguarding offence.
• The instigation and subsequent outcome of any child protection enquiry involving a child accommodated by the service.
• Any allegation that a child accommodated by the service has committed a serious offence.
• Any incident of child sexual exploitation or child criminal exploitation, or suspected child sexual or criminal exploitation.
• Any incident where an accommodated child goes missing or has an unexplained absence.

4.7 Notifications to the placing authority where a care home service is provided to children

Where a care home service is provided to children, the placing authority must be notified of:

• any abuse or allegation of abuse in relation to a child accommodated by the service that involves the provider or a member of staff;
• serious accident or injury to a child accommodated by the service;
• any occurrence of category 3 or category 4 pressure damage, or unstageable pressure damage;
• the outbreak of any infectious disease;
• any incident reported to the police;
• the death of a child accommodated by the service and the circumstances;
• any DBS referral under the Safeguarding Vulnerable Groups Act 2006;
• any allegation that a child accommodated by the service has committed a serious offence;
• any incident where an accommodated child goes missing or has an unexplained absence;
• the instigation and subsequent outcome of any child protection enquiry involving a child accommodated by the service;
• any incident of child sexual exploitation or child criminal exploitation, or suspected child sexual or criminal exploitation.

4.8 Notifications to the local authority, police and health board where a care home service is provided to children

Where a care home service is provided to children, {{org_field_name}} must also make the following notifications where applicable:

• The local authority for the area in which the home is situated must be notified of the death of a child and the circumstances, any incident of child sexual or criminal exploitation or suspected child sexual or criminal exploitation, and any incident where an accommodated child goes missing or has an unexplained absence.
• The appropriate police officer must be notified of any incident of child sexual or criminal exploitation or suspected child sexual or criminal exploitation.
• The health board in whose area the home is situated must be notified of the outbreak of any infectious disease and the death of a child and the circumstances.

4.9 Children admitted to or discharged from the home

Where {{org_field_name}} is registered to provide a care home service for children, the local authority for the area in which the accommodation is located must be notified without delay of every admission of a child into the accommodation and every discharge of a child from the accommodation, unless that local authority is also the placing authority for the child. The notification must include the information required by Regulation 61.

4.10 Family and representative communication

Individuals, representatives, families, parents or persons with parental responsibility will be informed of notifiable incidents where appropriate, lawful and consistent with the individual’s well-being, safeguarding needs, confidentiality and any legal restrictions. Information must not be shared where doing so could increase risk, prejudice a safeguarding enquiry or police investigation, or breach a court order.

5. Timeframes

Unless a specific timescale is stated in the Regulations or by CIW, notifications must be made without delay, in writing, and in the form and manner required by CIW. In practice, {{org_field_name}} will normally submit notifiable incident notifications to CIW within 24 hours of the event occurring or of the service becoming aware of the event.

The following specific timescales apply:

• Statement of Purpose revision: notify CIW and other required persons at least 28 days before the revised Statement of Purpose takes effect, unless the revision must take effect immediately.
• Change of principal office address: notify CIW at least 28 days before the change takes place.
• Expected absence of the Responsible Individual for 28 days or more: notify CIW at least 7 days before the absence begins.
• Unexpected absence of the Responsible Individual: notify CIW no later than 7 days after the absence begins.
• Unexpected absence of the Responsible Individual for 28 days or more where no prior notification has been given: notify CIW immediately on the expiry of 28 days from the start of the absence.
• Return from absence of the Responsible Individual: notify CIW without delay.
• Expected absence of the appointed manager for 28 days or more: the Responsible Individual must notify CIW at least 7 days before the absence begins.
• Unexpected absence of the appointed manager: the Responsible Individual must notify CIW no later than 7 days after the absence begins.
• Unexpected absence of the appointed manager for 28 days or more where no prior notification has been given: the Responsible Individual must notify CIW immediately on the expiry of 28 days from the start of the absence.
• Return from absence of the appointed manager: the Responsible Individual must notify CIW without delay.

Where staff are unsure whether an event is notifiable, they must escalate the matter to the Registered Manager or Responsible Individual immediately. The decision, rationale and any advice received from CIW, the local authority, health board, safeguarding team or police must be recorded.

6. Statutory Notification Checklist

Before deciding that an event is not notifiable, the Registered Manager or Responsible Individual must check whether the event involves any of the following:

• death of an individual;
• serious accident or injury;
• category 3 or category 4 pressure damage, or unstageable pressure damage;
• infectious disease outbreak;
• abuse or allegation of abuse involving the provider, staff or a volunteer;
• safeguarding referral or child protection enquiry;
• staff misconduct allegation;
• police report or police attendance;
• DoLS request to a supervisory body;
• event affecting safe service delivery;
• fire, utilities failure, premises damage, heating failure, fire alarm or safety device failure;
• significant staffing shortage;
• revision to the Statement of Purpose;
• change of provider name, directors, trustees, managing committee, partners or persons managing and controlling the organisation;
• bankruptcy, receivership, liquidation or similar financial/legal event;
• significant premises alteration, extension, additional premises or change of principal office;
• Responsible Individual absence, return from absence or ceasing to act;
• appointed manager appointment, absence, return from absence, ceasing to manage, or another person managing the service;
• any children’s care home specific event, including child exploitation, missing or unexplained absence, DBS referral, serious offence allegation, admission or discharge.

The completed checklist, decision and rationale must be retained with the incident record.

7. Roles and Responsibilities

Responsible Individual (RI)

The Responsible Individual is accountable for ensuring there are effective systems for identifying, recording, reviewing and submitting notifications. The RI must ensure that the provider’s policies and procedures are up to date, that staff understand notification requirements, that incidents and complaints are recorded accurately, and that matters requiring notification under Regulations 60 to 62 and 84 are acted upon. The RI must notify CIW of the events specified in Schedule 4, including appointment, absence, return from absence or cessation of the appointed manager, and any situation where someone other than the appointed manager is proposing to manage or is managing the service.

Registered Manager/Appointed Manager

The Registered Manager/Appointed Manager is responsible for day-to-day implementation of this policy. This includes ensuring immediate safety, coordinating internal reporting, assessing whether the event is notifiable, ensuring safeguarding referrals and other external referrals are made, preparing or submitting CIW notifications where authorised to do so, maintaining complete records, informing the RI, updating care plans and risk assessments, and ensuring follow-up actions are completed.

CIW Online Assistants

Where authorised by the Responsible Individual through CIW Online, an online assistant may prepare and submit permitted notifications on behalf of the service. Delegation does not remove the accountability of the service provider or Responsible Individual for the accuracy, completeness and timeliness of notifications.

Designated Safeguarding Lead (DSL)

Advises on Wales Safeguarding Procedures; ensures appropriate referrals to the Local Authority; supports multi-agency working; oversees staff debrief and support.

All Staff and Agency Workers

Immediately report incidents/concerns to the on-duty senior/manager; make factual records; preserve evidence; cooperate with investigations; maintain confidentiality under UK GDPR/DPA 2018.

8. Procedure

1. Identify and make safe

Prioritise immediate safety and medical help; for children, ensure a trauma-informed approach and contact parents/guardians unless this would increase risk.

2. Report internally

Staff inform the senior on duty/Registered Manager/DSL at once (verbally), followed by a written incident record before the end of the shift.

3. Assess and decide notifications

The Registered Manager (or RI/deputy) decides who must be notified (CIW, Local Authority, Police, Health Board/Public Health Wales, commissioners, parents/guardians).

4. Notify within required timescales

CIW notifications must be submitted through CIW Online, unless CIW directs otherwise. The notification must include accurate, factual and proportionate information, including:

• the date, time and location of the event;
• the person or people affected;
• what happened;
• immediate action taken to protect people;
• medical advice or treatment sought;
• safeguarding, police, health board, local authority or commissioner referrals made;
• family, representative or placing authority communication, where appropriate;
• current risks and control measures;
• any staff action, suspension, disciplinary action or DBS/professional referral being considered;
• planned follow-up actions and learning.

Where full information is not yet available, the initial notification must still be submitted without delay and updated when further information becomes available.

5. Check statutory notification category

The Registered Manager or Responsible Individual must check the event against the Schedule 3 and Schedule 4 notification categories before deciding that a CIW notification is not required. The decision and rationale must be recorded, including the name and role of the person making the decision.

6. Record and secure information

Store records securely in line with UK GDPR/DPA 2018; restrict access to those with a legitimate need to know; use anonymisation where appropriate.

7. Follow-up actions

Update care plans and risk assessments; provide staff and family/parent communication; arrange debriefs; offer wellbeing support to those affected.

8. Multi-agency working

Cooperate fully with safeguarding enquiries, Police investigations, coronial processes, and public health responses.

8.1 Pressure damage notifications

Any occurrence of category 3 or category 4 pressure damage, or unstageable pressure damage, must be notified to CIW without delay. The notification must include the date identified, body site, category, immediate treatment, whether a healthcare professional has reviewed the person, safeguarding considerations, action taken to prevent deterioration, communication with representatives or commissioners where appropriate, and any review of the person’s personal plan, risk assessment, equipment, repositioning regime, nutrition and hydration needs.

8.2 Deprivation of Liberty Safeguards notifications

Any request to a supervisory body in relation to the application of the Deprivation of Liberty Safeguards must be notified to CIW without delay. The record must include the reason for the request, the date submitted, the supervisory body contacted, whether an urgent authorisation is in place, the expiry date of any authorisation, and how the person’s rights, wishes, feelings and best interests are being protected.

8.3 Staff misconduct, criminal offences and professional referrals

Any allegation of misconduct by a member of staff must be assessed for notification to CIW. Where the allegation relates to abuse, neglect, improper treatment, unsafe practice, dishonesty, professional misconduct, failure to report abuse or suspected abuse, or any behaviour that may place individuals at risk, the Registered Manager must inform the Responsible Individual immediately and ensure that safeguarding, disciplinary, DBS, Social Care Wales, professional regulator and police referrals are considered.

CIW must also be notified without delay if the service provider, Responsible Individual or appointed manager is convicted of a criminal offence.

9. Learning, Review, and Improvement

• Post-incident review within 5–10 working days (earlier for high-risk incidents) to analyse causes, contributory factors, and what could be done differently.
• Action plans with responsible leads and timescales; track to completion.
• Trend analysis in monthly governance/quality meetings to identify patterns.
• Feedback loop to staff, people using the service, and (for children) parents/guardians where appropriate.
• Policy and training updates where learning indicates system changes are needed.

• The Responsible Individual will review notifications, incidents, safeguarding referrals, complaints, pressure damage, police incidents, DoLS notifications and service disruption events as part of governance and quality monitoring.
• Notification trends, themes, late notifications, missed notifications and corrective actions will be included in governance reporting and considered within the quality of care review process.
• Where a notification identifies a failure in policy, staffing, training, equipment, premises, infection prevention and control, safeguarding practice or management oversight, an action plan will be produced, monitored and signed off by the Registered Manager and Responsible Individual.

10. Training and Competence

All staff receive induction and refresher training covering:

• Recognising and responding to incidents, harm and abuse (adults and children)
• Wales Safeguarding Procedures and Local Authority referral routes
• Incident recording standards and CIW notification triggers
• MCA/DoLS (16+) and lawful, proportionate use of restraint
• Confidentiality, UK GDPR/DPA 2018, and information sharing in the public interest

• Regulation 60 and Schedule 3 notification triggers for care home services.
• Regulation 84 and Schedule 4 notification duties for the Responsible Individual.
• CIW Online notification process and delegated online assistant arrangements, where relevant.
• Recognising and escalating category 3, category 4 and unstageable pressure damage.
• DoLS request notification requirements.
• Staff misconduct, criminal offence, DBS and professional regulator referral triggers.
• Children’s care home additional notification duties, where the service accommodates or supports children.

11. Confidentiality and Information Governance

{{org_field_name}} will collect, record and share only information that is necessary, proportionate, accurate and lawful. Information relating to notifiable events will be kept securely and shared with CIW, local authorities, safeguarding teams, police, health boards, commissioners, the DBS, Social Care Wales, professional regulators, coroners or other relevant bodies where required by law, regulation, safeguarding procedures, public protection duties or the public interest. Information will be handled in accordance with UK GDPR, the Data Protection Act 2018, the Wales Safeguarding Procedures and the service’s records management and retention procedures.

12. Related Documents

• Safeguarding (Adults and Children) Policy – Wales
• Complaints and Whistleblowing Policy
• Incident Reporting and Investigation Procedure
• Positive Behaviour Support and Restrictive Practices Policy
• Data Protection and Confidentiality Policy
• Statement of Purpose – Wales service(s)

CIW Online and Regulatory Notifications Procedure

Duty of Candour Policy

Records Management and Retention Policy

Pressure Damage Prevention and Management Policy

Mental Capacity Act and Deprivation of Liberty Safeguards Policy

Infection Prevention and Control Policy

Business Continuity and Emergency Planning Policy

Missing Person Policy

Staff Disciplinary Policy

Recruitment, DBS and Fit Person Checks Policy

Children Missing from Care Policy, where applicable

Child Sexual Exploitation and Child Criminal Exploitation Procedure, where applicable

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