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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Management of Accidents, Incidents, and Near Misses Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} has a structured and effective system for managing accidents, incidents, and near misses. This policy ensures compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (including Regulation 12 Safe Care and Treatment and Regulation 20 Duty of Candour), the Care Act 2014, the Care Quality Commission (Registration) Regulations 2009 (statutory notifications), the Management of Health and Safety at Work Regulations 1999, RIDDOR 2013, and UK GDPR/Data Protection Act 2018. It provides clear definitions, roles and responsibilities, a step-by-step reporting process, investigation and learning requirements, support for affected individuals, external notification duties, documentation standards, and training/awareness expectations.

1.1 Definitions

Accident: An unplanned event that results in injury, ill health, or damage (e.g., a fall causing harm).

Incident: Any event that affects, or has the potential to affect, the safety, quality, or security of people, staff, visitors, property, medicines, or information (includes safeguarding concerns and security breaches).

Near Miss: An event that did not result in harm but had the potential to do so.

Serious Incident: An incident that results in (or had the potential for) serious harm, death, significant service disruption, or major safeguarding concerns, and which requires immediate escalation, thorough investigation, and consideration of external notifications.

Notifiable Safety Incident (Duty of Candour): An unintended or unexpected incident in care that appears to have resulted in death, severe harm, moderate harm, or prolonged psychological harm and triggers the statutory Duty of Candour.

RCA (Root Cause Analysis): A structured method to identify underlying causes and contributory factors to prevent recurrence.

2. Scope

This policy applies to all staff, volunteers, and contractors working within {{org_field_name}}. It covers all types of accidents, incidents, and near misses, including but not limited to:

• Injuries to the people we support, staff, or visitors.
• Medication errors.
• Safeguarding concerns.
• Falls, slips, or trips.
• Equipment failures.
• Environmental hazards.
• Security breaches.
• Infection control breaches.

3. Principles of Effective Accident, Incident, and Near Miss Management

{{org_field_name}} is committed to maintaining a safe environment through the following principles:

Reporting and Recording of Incidents

• Staff can report incidents directly to the Registered Manager, {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}, via email at {{org_field_registered_manager_email}} or by phone at {{org_field_registered_manager_phone}}.
• All accidents, incidents, and near misses must be reported immediately to a line manager or senior staff member.
• Reports must be documented using the Incident Report Form within 24 hours of the event.
• Incidents involving harm or potential harm to the people we support must be reported to the Registered Manager and Safeguarding Lead, {{org_field_safeguarding_lead_name}}, via email at {{org_field_safeguarding_lead_email}} or by phone at {{org_field_safeguarding_lead_phone}}, as required.
• RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013) reporting will be completed where required for serious incidents.
• Incident reports must be factual, objective, and comprehensive, avoiding speculation or assumptions.

Clear Incident Reporting Process

• Make safe: provide first aid, call emergency services if required, and protect others from further harm.
• Inform: immediately inform the most senior person on duty and the Registered Manager (or on-call manager {{out_of_hours}}).
• Safeguarding: if abuse or neglect is suspected, treat as a safeguarding concern and follow safeguarding procedures without delay.
• Record: complete the Incident Report Form as soon as possible and within 24 hours; include factual chronology, people involved, immediate actions, and any evidence preserved.
• Escalate: the senior person on duty will triage severity, decide on external notifications (see “External Reporting and Notifications”), and initiate an investigation.
• Candour: where the Duty of Candour criteria are met, inform the person (or representative) as soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred, provide a written apology, provide reasonable support, and keep them updated on findings and actions; a written record of all candour communications will be retained with the incident file.
• Follow-up: update risk assessments and care/support plans within 48 hours where relevant.

Notification decision rule (must consider all three routes)

When triaging any accident, incident or near miss, the Registered Manager (or the on-call manager) must consider and record whether the incident requires:

1. a Safeguarding referral (Care Act 2014) where abuse or neglect is suspected, alleged, or identified; and/or
2. a CQC statutory notification without delay where the incident meets a CQC notification category; and/or
3. a Duty of Candour response where it meets the threshold for a notifiable safety incident.
   More than one route may apply and, where relevant, these must be actioned in parallel (not sequentially). The incident record must show the decision made, who made it, the date/time, and any reference numbers.

Incident Documentation and Record-Keeping

• All incidents, accidents, and near misses are logged in the central Incident Register with a unique reference.
• Records include: completed Incident Report Form, body map (if applicable), witness statements, photographs or diagrams (where appropriate), associated MAR/care notes extracts, safeguarding referrals, notifications sent, and the investigation report with action plan.
• Preserve evidence proportionately (e.g., quarantine faulty equipment; retain CCTV in line with policy).
• Records are confidential, stored securely, and retained in line with {{org_field_name}}’s retention schedule and UK GDPR/Data Protection Act 2018.
• Learning summaries (anonymised) are shared with staff and used in training.

Investigation and Root Cause Analysis

Triage: the Registered Manager or Health and Safety Lead reviews every report within 1 working day to determine level of investigation.

Timeframes: fact-finding for low-risk incidents within 5 working days; RCA for serious/complex incidents commenced within 2 working days and normally concluded within 20 working days.

 Method: secure and review evidence; take statements; map the timeline; analyse contributory factors (people, process, place, equipment, communications, training).

CAPA: produce a Corrective and Preventive Action (CAPA) plan that is SMART (specific, measurable, achievable, relevant, time-bound) with named owners and due dates.

Verification: the Registered Manager monitors completion and tests effectiveness (e.g., spot checks, audits, data trends).

Feedback: share lessons learned with staff and—where appropriate—the people we support and families; update risk assessments, care/support plans, and policies.

Duty of Candour and Communication

• Under Regulation 20 (Duty of Candour), we ensure that:
  • The affected individual (or their representative) is informed of the incident as soon as possible.
  • A formal written apology is provided where appropriate.
  • They are updated on the investigation findings and actions taken to prevent recurrence.
• Families and external stakeholders will be informed transparently when serious incidents occur.

Support for Affected Individuals

• Provide timely clinical/first aid support and arrange medical review where required.
• Offer compassionate explanation, apology (where appropriate), and ongoing updates in accessible formats.
• Provide emotional support, advocacy, or signposting (e.g., PALS/independent advocacy).
• Review and, where necessary, adjust the person’s care/support plan, risk assessments, and reasonable adjustments.
• Offer staff debrief/wellbeing support following traumatic events.

Corrective Actions and Preventive Measures

• Following an investigation, an Action Plan will be developed to address the root causes.
• Actions may include:
  • Additional staff training.
  • Reviewing and updating policies and procedures.
  • Improving environmental safety measures.
  • Implementing new equipment or technology.
• Implementation of corrective measures will be monitored, and their effectiveness will be evaluated.

Learning from Incidents and Continuous Improvement

• Regular trend analysis is conducted to identify recurring patterns and systemic issues.
• Findings from incident reviews will be discussed in staff meetings and training sessions.
• Lessons learned will be incorporated into risk assessments, policies, and staff development programmes.
• Anonymised incident reports will be used in training scenarios to enhance learning.

Governance evidence and monitoring (Regulation 17)

Incident themes, investigation quality, Duty of Candour compliance, safeguarding outcomes, and completion/effectiveness of corrective and preventive actions (CAPA) will be monitored through monthly governance reporting. This will include key measures such as: time from incident to initial report, time to complete investigation, recurrence rates, and overdue actions. Learning will be used to update risk assessments, risk registers, staff training plans, supervision agendas, and service improvement plans. Governance records (including minutes, action logs, audits, and evidence of completion) will be retained and made available for internal audit and CQC inspection.

Training and Awareness for Staff and People We Support

• Staff receive training at induction and at least annually on: hazard recognition, reporting, Duty of Candour, safeguarding, RIDDOR awareness, incident investigation basics, record-keeping, and de-escalation.
• Role-specific training is provided for managers/investigators (e.g., RCA and CAPA).
• Scenario-based exercises and learning bulletins are used to embed learning from trends and serious incidents.
• People we support are offered accessible information on how to raise concerns or report incidents, including easy-read and alternative communication formats.

External Reporting and Notifications

We will submit CQC statutory notifications without delay when an incident, event or change meets the criteria in the Care Quality Commission (Registration) Regulations 2009 (as amended) and CQC guidance. Notifications will be submitted via CQC’s online portal (or the approved method at the time), and the Incident Register will record: the notification type, date/time submitted, reference number, any follow-up requested by CQC, and the outcome.

CQC (statutory notifications) – we will notify CQC without delay of, as applicable:

• Death of a person using the service (including where the death may be related to how the regulated activity was provided).
• Serious injury to a person using the service (see definition below).
• Allegations of abuse / abuse suspected or confirmed (safeguarding).
• Events that stop, or may stop, the service running safely and properly (e.g., fire, flood, major utilities failure, serious staffing shortfall impacting safety, serious infection control failure).
• Police involvement in an incident relating to a regulated activity (including where police attend or investigate).
• Deprivation of Liberty Safeguards (DoLS): the outcome of an application to deprive a person of their liberty (where applicable).
• Unauthorised absence / missing person where it meets the CQC notification criteria.
• Any other notifiable event/change required by the CQC Registration Regulations and CQC notification guidance.

For the purpose of CQC notification, a “serious injury” includes (in the reasonable opinion of a healthcare professional) an injury that results in, or is likely to result in, permanent or long-lasting impairment (sensory, motor, or intellectual), significant disfigurement, or prolonged pain or psychological harm, or otherwise meets the Regulation 18 threshold. If the serious injury is the result of an assault, we will use the CQC “allegation of abuse” route.

Notify external bodies without delay where required. This includes, as applicable:

• Local Authority Safeguarding: adult safeguarding concerns under the Care Act 2014 to {{org_field_local_authority_authority_name}}; for children/young people, report to {{org_field_children_multi_agency_safeguarding_hub_authority_name}} (MASH) and the relevant children’s safeguarding team.
• RIDDOR (HSE) – legal reporting timescales

Where an incident is RIDDOR-reportable, we will:

• Notify the HSE without delay (by the quickest practicable means) for work-related fatalities and specified injuries; and
• Ensure the written report is submitted within 10 days of the incident; and
• For over-seven-day incapacitation of a worker, ensure the report is submitted within 15 days of the incident.
  The Health & Safety Lead (or Registered Manager where delegated) will keep evidence of reporting (submission confirmation and reference numbers) within the incident record.
• Police: where a crime is suspected or required to protect individuals.
• Commissioners/ICB/NHS partners: where contractually required or in line with serious incident arrangements.
• Medicines & Healthcare products Regulatory Agency (MHRA): report serious incidents involving medicines or medical devices (e.g., Yellow Card).
• Ofsted (where applicable): if {{org_field_name}} provides any service regulated by Ofsted (e.g., children’s services), make required notifications to Ofsted and the relevant Local Authority.

All external reports are approved by the Registered Manager (or delegate) and logged in the Incident Register with dates, references, and outcomes.

Multi-agency meetings may be convened to coordinate safeguarding, risk management, and learning.

Emergency Response to Major Incidents

• A Major Incident Plan is in place for significant events such as fires, pandemics, security threats, or major health and safety failures.
• Staff are trained on emergency response procedures, including evacuation, first aid, and crisis management.
• The Business Continuity Plan ensures service continuity during major disruptions.

Confidentiality and Data Protection

• Incident reports and investigations are confidential and stored securely.
• Information is only shared with authorised personnel on a need-to-know basis.
• Compliance with GDPR (General Data Protection Regulation) ensures the safe handling of personal data.

4. Roles and Responsibilities

Nominated Individual: Provides governance oversight; assures that investigation quality, learning, and external notifications are completed and that trends inform service improvement.

Registered Manager: Overall lead for incident management; ensures immediate safety actions, triage, statutory notifications (CQC, LA, etc.), Duty of Candour, investigations/CAPA, and communication with people and representatives.

Health and Safety Lead: Leads risk assessments, supports/undertakes investigations and trend analysis, and ensures RIDDOR compliance.

Safeguarding Lead: Oversees safeguarding referrals, strategy discussions, and multi-agency coordination; assures protection plans are enacted.

Data Protection Officer (or Lead): Ensures incident records, evidence, and notifications comply with UK GDPR/Data Protection Act 2018.

On-Call Manager: Provides out-of-hours escalation and decision-making {{out_of_hours}}.

All Staff and Volunteers: Take immediate safety actions, report incidents without delay, complete records within 24 hours, cooperate with investigations, and participate in learning and corrective actions.

5. Related Policies

This policy should be read in conjunction with:

• SL11 – Safe Care and Treatment Policy
• SL13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• SL16 – Health and Safety at Work Policy
• SL20 – Duty of Candour Policy
• SL25 – Notification of Other Incidents Policy
• SL30 – Emergency and Business Continuity Plan

6. Policy Review

This policy will be reviewed annually or sooner if legislative changes, CQC requirements, or organisational needs necessitate an update. Any updates will be communicated to all staff to ensure continued compliance and best practices in accident, incident, and near-miss management.

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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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.