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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 all significant incidents affecting the safety, well-being, and quality of care provided by {{org_field_name}} are promptly reported, recorded, and escalated in compliance with Care Inspectorate Wales (CIW) regulations.

This policy ensures that:

• All reportable incidents are notified to CIW, relevant authorities, and key stakeholders as required.
• Incidents are properly recorded, investigated, and addressed to prevent recurrence.
• Service users, staff, and visitors are safeguarded through effective incident management.
• Lessons learned from incidents contribute to continuous improvement in service delivery.

2. Scope

This policy applies to:

• All care staff and support workers, who must report incidents immediately.
• The Registered Manager and Responsible Individual, who are responsible for notifying CIW and other authorities.
• Service users and their families, ensuring they are informed and supported following an incident.
• Contractors and external professionals, who must comply with incident reporting protocols.

3. Legal and Regulatory Framework

This policy aligns with the following legislation and CIW regulations:

• The Regulation and Inspection of Social Care (Wales) Act 2016, which requires timely notification of incidents to regulators​.
• The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (as amended, including the 2024 Amendment Regulations) – in particular Regulation 60 and Schedule 3 (Notifications by the service provider).
• Statutory guidance for service providers and responsible individuals of care home and domiciliary support services (Welsh Ministers, updated 2024) issued under section 29 of RISCA – providers must have regard to this guidance when meeting Regulation 60 notification requirements.
• The Health and Safety at Work etc. Act 1974, ensuring safe working conditions and reporting of workplace incidents.
• The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013, which require reporting of specific incidents to the Health and Safety Executive (HSE).
• The Social Services and Well-being (Wales) Act 2014, which reinforces safeguarding duties and incident reporting responsibilities.

4. Types of Incidents That Must Be Notified

How notifications are made to CIW (Regulation 60)

All notifications required under Regulation 60 and Schedule 3 are made without delay and in writing, and must be submitted in the manner and form required by CIW. Notifications must include details of the event, what immediate action was taken, who has been informed, and any ongoing risk controls or investigation steps.
{{org_field_name}} makes statutory notifications to CIW using CIW Online, unless CIW explicitly directs an alternative method.

The following categories of incidents must be reported to CIW and/or other relevant bodies:

4.1 Death of a Service User

For domiciliary support services, CIW will be notified without delay (normally within 24 hours) where a service user’s death:

• Any death of a service user while receiving care, whether expected or unexpected, must be reported.
• occurs during the delivery of the service (e.g., during a visit), and/or
• is associated with a notifiable event such as a serious accident or injury, a safeguarding concern/allegation involving staff, a medication error requiring clinical intervention, an outbreak, or an incident reported to the police.

Where the event is also reportable under RIDDOR, the Registered Manager will ensure the appropriate report is made to the HSE.
CIW notification will be made in writing via CIW Online.

How we manage this efficiently:

• Immediate reporting to emergency services (if required).
• Completion of an internal death notification report within 24 hours.
• Notification to CIW without delay (and normally within 24 hours of the event occurring, or within 24 hours of the service becoming aware of the event), and in writing via CIW Online.

4.2 Allegations of Abuse or Neglect

• Any suspected or confirmed cases of physical, emotional, financial, or sexual abuse must be reported to CIW, safeguarding teams, and police (if applicable).

How we manage this efficiently:

• Immediate protection measures are put in place to safeguard service users.
• The Safeguarding Lead at {{org_field_name}} takes responsibility for handling and escalating cases.
• All staff receive safeguarding training, enabling them to recognise and report concerns promptly​.

4.3 Serious Injuries to Service Users or Staff

• Fractures, head injuries, burns, hospital admissions, or any injury that significantly impacts well-being must be reported to CIW and RIDDOR (if applicable).

How we manage this efficiently:

• Incident report completed within 24 hours.
• Investigation conducted, including root cause analysis.
• Preventative measures implemented to avoid recurrence.

4.4 Medication Errors

• Incidents involving incorrect medication administration, missed doses, overdose, or adverse reactions must be reported.
• If a service user requires hospitalisation or medical intervention, CIW must be informed.

How we manage this efficiently:

• Immediate medical assistance sought (if required).
• Medication error report completed, reviewed by the Registered Manager.
• Staff retraining provided, and policies revised if necessary.

4.5 Infection Outbreaks

• Outbreaks of infectious diseases (e.g., COVID-19, norovirus, flu) affecting service users or staff must be reported to:
  • CIW
  • Public Health Wales
  • Local Health Protection Teams

How we manage this efficiently:

• Immediate isolation and infection control measures activated.
• Daily reporting to Public Health Wales during outbreaks.
• Staff and service users advised on infection prevention procedures.

4.6 Service Disruptions and Emergencies

• Any serious operational disruption (e.g., power outages, IT failures, severe weather, staff shortages) that affects service delivery must be reported to CIW.
• This includes (but is not limited to) events that prevent, or could prevent, the service from continuing to provide care and support safely, such as: an insufficient number of suitably qualified/competent staff, or interruptions/failures affecting premises used by the provider for regulated service purposes where relevant (e.g., utilities or safety systems impacted for a continuous period of more than 24 hours).

How we manage this efficiently:

• Emergency contingency plans activated.
• Alternative care arrangements put in place to maintain continuity.
• Incident report sent to CIW without delay (and normally within 24 hours of the event occurring, or within 24 hours of the service becoming aware of the event), and in writing via CIW Online.

4.7 Allegations Against Staff

• Any allegations of misconduct, abuse, or malpractice against staff members must be reported to CIW and Disclosure and Barring Service (DBS), if required.

How we manage this efficiently:

• Immediate suspension or reassignment of staff member (if necessary).
• Investigation conducted in line with safeguarding policies.
• Findings reported to CIW and other authorities.

4.8 Category 3 or 4 pressure damage / unstageable pressure damage

Any occurrence of a category 3 or category 4 pressure damage, or unstageable pressure damage, in relation to an individual receiving care and support from the service, must be notified to CIW without delay (normally within 24 hours) and in writing via CIW Online.

4.9 Any incident reported to the police

Any incident connected with the service that is reported to the police (including suspected crimes against or involving a person using the service, or serious crimes linked to staff conduct while delivering care) must be notified to CIW without delay (normally within 24 hours) and in writing via CIW Online.

4.10 Criminal convictions of key individuals

If the service provider, responsible individual, or appointed manager is convicted of a criminal offence, CIW must be notified in writing via CIW Online without delay.

4.11 Other statutory notifications to CIW (Schedule 3 – Regulation 60)

In addition to incident-based notifications, the Registered Manager/Responsible Individual will ensure CIW is notified (via CIW Online) of the following statutory events within the required timescales:

• Any revision to the Statement of Purpose – at least 28 days before the revision takes effect.
• Provider name changes, and (where applicable) changes to directors/trustees/managing committee or management/control of the provider body.
• Expected absence of the Responsible Individual for 28 days+ (notify 7 days prior), unexpected absence (notify no later than 7 days after it starts), unexpected absence reaching 28 days with no prior notice (notify immediately on expiry of 28 days), and return from absence.

5. Incident Reporting and Investigation Process

5.1 Immediate Response

1. Ensure safety – Take urgent action to protect individuals involved.
2. Seek medical help if required.
3. Report the incident immediately to the Registered Manager or Responsible Individual.

5.2 Documentation and Internal Reporting

1. Incident report form completed within 24 hours.
2. Gather witness statements if applicable.
3. Review CCTV or other relevant records (if available).

5.3 Notification to CIW and Other Authorities

The Registered Manager (or authorised delegate) will submit statutory notifications to CIW without delay and in writing, and in the manner and form required by CIW, using CIW Online. Notifications will include details of the event, immediate actions taken, who has been informed, and the plan to manage ongoing risk and complete any investigation.

Where relevant, additional notifications will be made to other bodies (e.g., safeguarding team, police, Public Health Wales / health protection, HSE under RIDDOR), in line with their requirements.

5.4 Investigation and Follow-Up Actions

1. Root cause analysis conducted to determine contributing factors.
2. Preventative measures implemented to avoid recurrence.
3. Lessons learned shared with staff through training sessions.

6. Responsibilities in Incident Reporting

• Registered Manager: Ensures all reportable incidents are notified to CIW.
• Care Workers: Report incidents immediately and document details accurately.
• Service Users and Families: Encouraged to report concerns and incidents.
• Responsible Individual: Monitors trends and ensures compliance with regulatory requirements.

7. Training and Staff Awareness

• All staff receive mandatory training on incident reporting and notification procedures.
• Refresher training provided annually.
• Managers conduct periodic audits to ensure compliance.

8. Related Policies

This policy aligns with:

• Safeguarding Adults Policy (DCW13)​.
• Health and Safety at Work Policy (DCW16)​.
• Risk Management and Assessment Policy (DCW18)​.
• Management of Accidents, Incidents, and Near Misses Policy (DCW24)​.

9. Policy Review

This policy will be reviewed annually or sooner if required due to changes in legislation, business needs, or CIW regulations. The Registered Manager and Responsible Individual are responsible for ensuring its accuracy and implementation.

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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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