1  Introduction

Emma Way Associates Ltd (EWA) is committed to providing a safe and healthy work environment.  The purpose of this policy is to ensure that all incidents and near misses (including minor incidents) are reported, recorded and investigated. Reporting and sharing information with relevant parties creates an opportunity to answer the questions of what happened and why, and to determine how to prevent a reoccurrence.

EWA expects that managing all incidents and near misses according to this policy will help to ensure:

• A culture of openness.
• Prompt and clear gathering of facts to enable appropriate action to be taken.
• Prompt communication with those involved, staff in general and, where appropriate, other companies.
• Identification of patterns and trends in the occurrence of incidents and near misses.
• Implementation of effective preventive actions to avoid similar occurrences.
• Early warning of potential litigation.
• Review of local procedures as a result of incidents and near misses.
• That all involved within an incident are safe and that the reason for the incident is risk assessed to minimise any recurrence.

2  Scope of the Policy

This policy concerns the reaction to reporting and investigation of all incidents and near misses within Emma Way Associates Ltd (EWA). It includes all such occurrences that could affect our ability to achieve our organisational objectives.  This policy is required practice for associates, case managers, support staff and EWA employees.

3  Principles and Standards

The specific regulations that govern EWA’s registration are the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 12: Safe care and treatment and Regulation 20: Duty of candour and the Care Quality Commission (Registration) Regulations 2009 Regulation 18: Notification of other incidents. These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect.

The outcome of this policy is that the health, safety and welfare of clients, their relatives or representatives and staff will be promoted and protected. EWA are registered with the Care Quality Commission and are required to make statutory notifications. It is expected that all incident reports are completed as a matter of urgency to ensure that compliance is achieved.

Our aim is to ensure that the highest quality of service delivery will be upheld at all times.

4  Definitions

Client Safety is the process by which an organisation makes client care safer. This should involve risk assessment, the identification and management of client related risks, the reporting and analysing of incidents, and the capacity to learn from and follow up on incidents and implement solutions to minimise the risk of them recurring.

A Client Safety Incident is any unintended or unexpected incident, which could have, or did, lead to harm for one or more clients receiving social or health care.

An Incident (sometimes known as an Adverse Event) is any event or circumstance that did lead, or could have led, to harm, loss or damage to people, or property, whilst engaged in EWA services, or on EWA business.

Near misses, accidents, and serious incidents are specific types of incidents:

• An Accident is an incident that caused personal injury or damage to property.
• A Near Miss is an incident that did not lead to harm, loss or damage, but could have.
• A Serious Incident is an incident that had a major or catastrophic outcome.

All of the above are to be recorded and notified to the appropriate person as detailed in sections 6 and 7 of this policy.  All records are incidents are forwarded to the Compliance Manager at EWA to record and assess.

5  EWA’s Response to Incidents/Near Misses

All members of staff have an important role to play in identifying, assessing and managing risk. EWA will not seek to apportion blame unnecessarily or unfairly. All staff are strongly encouraged to report any situation where things have or could have gone wrong, as EWA has a strong desire to learn from incidents and near misses to prevent reoccurrence and ensure that the correct management strategies are in place.

All reported incidents and near misses will be reviewed and investigated where necessary. The findings of each such investigation will be judged on its individual merits, bearing in mind all relevant factors (such as the circumstances, and the experience and seniority of the employee(s) concerned).

In some cases, it may be necessary to consider disciplinary action. Some examples of the kind of situations where EWA may consider disciplinary action are as follows:

• Illegal Acts. Acts which are against the law, eg assaulting a colleague.
• Malicious Acts. Acts intending to cause harm which the individual knew was likely to be the result, eg deliberately releasing confidential information.
• Reckless Acts. Deliberately taking an unjustifiable risk where the member of staff either knew of the risk or they deliberately closed their mind to its existence (eg working while under the influence of alcohol or repeatedly making the same careless mistake). If it becomes clear as part of the initial investigation into the incident/near miss that this may be a potential disciplinary matter, then a separate disciplinary investigation will be commenced (this investigation may run concurrently with the incident/near miss investigation).

6  The Procedure

Risk management provides a system that allows three separate but interlinked strands of work to be carried out throughout the organisation: action, advice and assurance.

Each strand of this system requires different activities to be carried out within EWA for the management and investigation of incidents and near misses.

• Action – Making sure that the right things get done.
• Advice – Providing leadership and facilitation on opportunities, methods and objectives.
• Assurance – Being confident that all risks are being managed appropriately.

Action

It is important to recognise that the most crucial aspect of the implementation of this policy is the immediate response to incidents and near misses made by individuals throughout the organisation. The first priority of anyone involved in an incident or near miss should be to ‘make it safe’.

Report and Investigate

The Incident and Near Miss Report Form and accompanying completion guidance can be found at Incident and Near Miss Report Form , on line support worker folder or by calling the EWA office. All accidents must be reported to the Case Manager by email who will then forward the Incident and Near Miss Report Form to the Compliance Manager.  In the Case Manager’s absence the Incident and Near Miss Report Form must be sent to office@emmaway.uk . 

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR), place a legal duty on:

• Employers.
• Self-employed people.
• People in control of work premises.

to report and keep records of:

• Work related deaths.
• Major injuries or over three day injuries.
• Work related diseases.
• Dangerous occurrences (near miss accidents).

The easiest way to do this is by calling the Incident Contact Centre (ICC) on 0345 300 9923 (opening hours Monday to Friday 8.30 am to 5 pm). The person reporting the accident will be sent a copy of the information recorded and given the opportunity to correct any errors or omissions.

NB. Copies of submitted RIDDOR forms are sent to the employers/duty holders regardless of who has submitted the report.

Reporting accidents and ill health at work is a legal requirement. The information enables the Health and Safety Executive (HSE) and local authorities, to identify where and how risks arise, and to investigate serious accidents.

Advice

In relation to the reporting of accident and incidents, EWA will:

• Maintain up to date records. 
• Identify the level of investigation required.
• Support investigations, report findings and make recommendations as appropriate.
• Provide training on implementation of the policy.
• Provide a main contact of the Compliance Manager for issues relating to incidents.
• Notify the Care Quality Commission and/or HSE if required.

Assurance

Case Managers and Compliance Manager will:

• Be aware of incidents occurring in their teams/areas of work.
• Provide support and advice to, where applicable, client(s), team leader(s), responsible person(s) and the Registered Manager.

 

The Registered Manager will:

• Notify the Care Quality Commission when required to comply with EWA’s registration.

The Compliance Manager will:

• Collate and analyse data showing trends and patterns.
• Monitor the implementation of recommendations.
• Consider any investigation report commissioned as a result of a serious incident, consider significant trends, and approve appropriate recommendations.
• Consider some individual incidents and near misses, monitor trends and commission further work to investigate specific incidents or trends.

7  Reporting and Communication Flow

In the case of a serious incident, the Registered Manager must be contacted immediately or as soon as reasonably practicable. The out of hours contact number is available 24 hours per day, every day of the year.

EWA will accept reports of near misses and incidents by any of the following methods:

• Email office@emmaway.uk
• Telephone 01664 840730. An out of hours number is available 24 hours per day.
• Post.
• Verbal

However, certain core information is required in all cases. This information is set out in the EWA Incident and Near Miss Report Form . This form is available to all staff. Blank forms are in the client’s online support worker folder, following the link Incident and Near Miss Report Form or may be requested from the EWA office. This information must be reported to the Compliance Manager.

If a form is not used to report the incident or near miss, the information reported may, if appropriate, be transcribed onto a form. A copy of the information recorded will be given to all affected staff.

A copy of the information used to report the incident or near miss will be kept by the Compliance Manager in the Reported Incident or Near Miss File. A copy will also be placed in the online client’s folder and the staff file where necessary. All related documentation will be stored alongside the initial report. The Compliance Manager will offer advice if necessary to staff reporting the incident or near miss regarding the grading it is allocated and whether, based on that grading, any further investigation or action should be carried out. In addition, the Registered Manager will support the Compliance Manager with any recommended investigation to help ensure a consistent application of the ‘fair blame’ approach.

A ‘fair blame’ culture is one in which staff are not blamed, criticised or disciplined as a result of a genuine slip or mistake that leads to an incident. Disciplinary action may however still follow an incident that occurred as a result of misconduct, gross negligence or an act of deliberate harm.

All information is kept confidential. No investigation reports or data analyses will name any individuals involved.

8  Incident and Near Miss Investigation

All incident and near miss investigations will be based on the principles of system analysis. This shifts attention from individuals to more general organisational issues. The occurrence of an incident or near miss, or an error, however serious the outcome, is not in itself evidence of neglect, carelessness or dereliction of duty. An investigation can be carried out at one of several levels in the organisation.

Low Incidents and Near Misses

Most incidents and near misses will be graded into these less serious categories and, once appropriate action has been taken, they will require no further investigation. They will however be exceedingly useful in trend analysis carried out by the Compliance Manager.

Moderate and Significant Incidents and Near Misses

Moderate and significant incidents and near misses will be investigated by the Compliance Manager or a Senior Manager within EWA. The Registered Manager is required to report the incident to the Care Quality Commission as a reportable notification.

9  Feedback and Training Plan

All staff are required to read and understand this policy. All persons responsible for staff are required to read and understand this policy in order that they can support their staff in the event of a near miss or an incident and any subsequent investigation. In addition, the following feedback and training will be provided:

• List of issues displayed in support worker folders where appropriate.
• Feedback to individuals affected.
• Induction training.

10  Review

The EWA Incident and Near Miss Reporting Policy and Procedure and all other policies are reviewed annually.

It is important that the facts of the event are recorded as soon as possible so that they are fresh in people’s minds and any necessary investigation can proceed without delay. Therefore, this form should be completed and sent to the team leader/case manager or EWA office within 24 hours of the event.

PERSON COMPLETING THE FORM

The person completing the form may not be the person affected by the near miss or incident. Fill in your details in this section if you are completing the form. Investigators may need to contact you for further information.

DESCRIPTION OF EVENT

The event must be described in as much detail as possible. Include ONLY facts with no opinion. State:

• What happened
• Anything (equipment, documentation etc.) involved with the event
• What the outcome was
• If an incident is involving a member of staff and it is likely to result in time off work this must be noted on the report. If the affected person subsequently has time off that may be connected to the incident, this must be reported.
• There may be issues that arise that you would prefer to be dealt with confidentially. Please contact EWA to enable this.
• Detail any injury, damage or loss sustained if relevant.
• Note the names of any witnesses. Care must be taken to ensure that those who are not members of staff do not mind being noted as witnesses to the event.

ACTION TAKEN AT THE TIME

• Detail the action taken at the time of the event. This also must ONLY be fact. How the near miss or incident was managed, what happened, how was the immediate threat removed or reduced?
• What further action is proposed?

PASS FORM ONWARDS

Send the form or pass the information required on the form to the team leader/case manager or EWA office. The case manager or appropriate other will assess the future risk associated with the near miss or incident and support further action, if necessary, to comply with statutory regulations and requirements.

For further information please refer to the EWA Incident and Near Miss Reporting Policy and procedure.

Thank you for reporting this incident.