--- title: Management of Accidents, Incidents, and Near Misses Policy and Procedure | Homecare Services & Domiciliary Care canonical: https://www.thegoodplace.care/policies-and-procedures/management-of-accidents-incidents-and-near-misses-policy-and-procedure last updated: 2026-03-18 20:08:36 GMT version: 1 --- # Management of Accidents, Incidents, and Near Misses Policy and Procedure This policy ensures that all accidents, incidents, and near misses are appropriately recorded, investigated, and used to implement preventative measures, fostering a culture of continuous improvement and risk reduction. ## 1. Governance 1.1. This is the Management of Accidents, Incidents, and Near Misses Policy and Procedure for The Good Place Home Care Services Limited. 1.2. The Good Place Home Care Services Limited will be referred to in this document as "The Good Place Home Care Services Limited","The Good Place","We","Us", or "Our". 1.3. Our registered address is: 186 Wetmore Road, Burton-on-Trent, Staffordshire, DE14 1QZ. 1.4. We can be contacted by:- - a. Telephone: [01283 296 337](tel:01283 296 337) - b. Email: Please use our contact form at https://www.thegoodplace.care/contact - c. Post: The Good Place, 186 Wetmore Road, Burton-on-Trent, Staffordshire, DE14 1QZ 1.5. Words importing one gender include all genders, and words in the singular include the plural and vice versa, unless the context requires otherwise. 1.6. Document control sheet:- Document fingerprint: GOV-2103-V1 Document owner: Dean Hill (Nominated Individual) Document version: 1 Document status: Approved on 18/03/2026 by the Dean Hill (Nominated Individual) Document review cycle: Annually or sooner if legislation or guidance changes. Next review planned for March 2027 ## 2. Purpose 2.1. To establish a structured and efficient approach to the management, reporting, investigation, and prevention of accidents, incidents, and near misses within The Good Place. 2.2. To ensure that we fulfil the legal and regulatory responsibilities. 2.3. To support us to meet, and be able to evidence compliance with, the following CQC Single Assessment Framework quality statements:- Learning culture: We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices. Safeguarding: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. We make sure we share concerns quickly and appropriately. Involving people to manage risks: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them. Safe environments: We detect and control potential risks in the care environment. We make sure that equipment, facilities and technology support the delivery of safe care. Infection prevention and control: We assess and manage the risk of infection. We detect and control the risk of it spreading and share any concerns with appropriate agencies promptly. Assessing needs: We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them. Delivering evidence-based care and treatment: We plan and deliver people’s care and treatment with them, including what is important and matters to them. We do this in line with legislation and current evidence-based good practice and standards. How staff and teams work together: We work effectively across teams and services to support people. We make sure they only need to tell their story once by sharing their assessment of needs when they move between different services. Workforce wellbeing and enablement: We care about the wellbeing of our staff, and we support and enable them to deliver person-centred care. Listening to and involving people: We make it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. We involve them in decisions about their care and tell them what’s changed as a result. Governance, management and sustainability: We have clear responsibilities, roles, systems of accountability and good governance. We use these to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate. Learning, improvement and innovation: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research. ## 3. Scope 3.1. This policy applies to:- - a. All employees, including care workers, administrative staff, and management. - b. Service users and their families, ensuring a safe care environment. - c. Visitors, contractors, and third-party service providers. - d. Interactions with regulatory and oversight bodies, including the Care Quality Commission (CQC) and local authorities/ Integrated Care Boards, to meet our notification, reporting and assurance responsibilities. ## 4. Policy Statement 4.1. This policy ensures that all accidents, incidents, and near misses are appropriately recorded, investigated, and used to implement preventative measures, fostering a culture of continuous improvement and risk reduction. 4.2. By implementing a clear reporting system and proactive safety measures, we ensure the health, safety, and well-being of service users, staff, and visitors while complying with Care Quality Commission (CQC) regulations and Health and Safety Executive (HSE) guidelines. ## 5. Legal & Regulatory Framework 5.1. This policy is guided by:- - a. Health and Safety at Work etc. Act 1974 – general duties to prevent harm. - b. Management of Health and Safety at Work Regulations 1999 – risk assessment and control measures. - c. Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013 – legal duties and time limits for reporting certain work-related events to HSE. - d. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – including Regulation 9 (Person-centred care), Regulation 12 (Safe care and treatment) and Regulation 20 (Duty of candour). - e. Care Quality Commission (Registration) Regulations 2009 – Regulation 16 (Notification of death of a service user) and Regulation 18 (Notification of other incidents). - f. Care Act 2014 (Section 42) and Care and Support Statutory Guidance – adult safeguarding duties and multi-agency working. - g. UK General Data Protection Regulation (UK GDPR) and Data Protection Act 2018 – requirements for lawful, fair and transparent processing, data minimisation, retention and security when recording and sharing incident information (see ICO guidance). - h. CQC Single Assessment Framework (SAF) – with particular reference to the Safe, Effective, Responsive and Well-led quality statements relating to learning culture, risk management, safeguarding, governance and involvement of people. - i. Local Safeguarding Adults Board (SAB) multi-agency policies and procedures – including processes for raising concerns, Section 42 enquiries, and Safeguarding Adults Reviews (SARs). - j. NHS England and CQC guidance on learning from patient safety incidents and developing a positive safety culture, as adapted for adult social care services. - k. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 13 (Safeguarding service users from abuse and improper treatment), including requirements relating to restraint and restrictions, and Regulation 17 (Good governance), which requires providers to assess, monitor and improve the quality and safety of services, including through learning from incidents and near misses. 5.2. The Good Place is fully committed to meeting the requirements of the Accessible Information Standard (AIS), as set out by NHS England. This means we will ensure that people with a disability, impairment, or sensory loss receive information and communication support that they can understand and use effectively. This may include large print, easy-read versions, audio formats, or the use of interpreters and communication aids. See our [Accessible Information Standard (AIS) Policy and Procedure](https://www.thegoodplace.care/policies-and-procedures/accessible-information-standard-ais-policy-and-procedure) for further details. 5.3. We also comply with the Equality Act 2010 and are fully committed to promoting diversity, and human rights in all aspects of our service provision and employment practices. We are dedicated to ensuring that all individuals, including staff, service users, and stakeholders, are treated fairly, with dignity and respect, and without discrimination. We will also make reasonable adjustments so that no individual is treated less favourably when using our service. This includes supporting people with protected characteristics such as age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. See our [Equality, Diversity and Human Rights Policy and Procedure](https://www.thegoodplace.care/policies-and-procedures/equality-diversity-and-human-rights-policy-and-procedure) for further details. ## 6. Roles & Responsibilities 6.1. All employees are required to:- - a. Attend mandatory health and safety training covering accident prevention and response. - b. Understand their role in incident reporting and documentation. - c. Follow emergency protocols and cooperate with investigations. - d. Participate in post-incident debriefings and feedback sessions. - e. Follow lone-working and home-visit procedures, including any local guidance on personal safety, contacting the office, and emergency escalation when an incident occurs in a person’s own home or in the community. - f. Ensure that any incident in a person’s home is reported both through The Good Place’s systems and, where appropriate, to family/informal carers, community health professionals and other agencies involved in the person’s care, in line with consent, safeguarding duties and information-sharing agreements. - g. Report accidents, incidents, near misses and concerns openly and honestly, knowing that The Good Place promotes a “Just Culture” in which individuals are treated fairly, the focus is on learning and system improvement, and disciplinary action is reserved for wilful or reckless behaviour. 6.2. The Registered Manager is responsible for:- - a. Ensuring statutory notifications to CQC (Regs 16 and 18) are submitted without delay using current forms/portal. - b. Ensuring RIDDOR reports are made to HSE within required time limits and that RIDDOR records are retained ≥3 years. - c. Overseeing application of the duty of candour (Reg 20) when thresholds are met and assuring evidence of apologies, written records and learning. - d. Coordinating safeguarding referrals to the local authority (Care Act s42). - e. Ensuring regular analysis of accidents, incidents and near misses (including medicines incidents and falls) to identify themes, trends and learning, and presenting this information through The Good Place’s governance and quality assurance processes. - f. Making sure that learning and required actions from incidents, complaints, safeguarding enquiries and external reviews (for example, CQC inspections, Local Authority contract monitoring, Safeguarding Adults Reviews) are captured in an improvement plan, implemented and monitored. - g. Ensuring that people using the service, and where appropriate their families/representatives, are informed about incidents affecting them and involved in decisions about actions taken to reduce future risk. - h. Promoting a positive safety culture and psychological safety by encouraging staff to raise concerns and report incidents and near misses without fear of blame, and by ensuring responses to incidents are fair, proportionate and focused on learning and improvement. ## 7. Data Protection & Confidentiality 7.1. At The Good Place, we recognise that protecting an individual's confidentiality and ensuring compliance with data protection laws are fundamental to ethical and legal care practices, especially when handling personal and sensitive health data. 7.2. See our [Confidentiality and Data Protection (UK GDPR) Policy and Procedure](https://www.thegoodplace.care/policies-and-procedures/confidentiality-and-data-protection-uk-gdpr-policy-and-procedure) for full details on how personal and health data must be obtained, stored, shared, and processed in accordance with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018. 7.3. While we will normally seek consent before sharing personal information about incidents, there are situations where we may need to share information without consent, for example where this is required by law (such as statutory notifications to CQC, RIDDOR reports to HSE), in order to protect an adult at risk under safeguarding duties, or to prevent or detect serious crime. Any such sharing will follow our [Confidentiality and Data Protection (UK GDPR) Policy and Procedure](https://www.thegoodplace.care/policies-and-procedures/confidentiality-and-data-protection-uk-gdpr-policy-and-procedure) and be limited to what is necessary and proportionate. ## 8. Definitions 8.1.Accident: An unplanned event arising out of or in connection with our work that results in injury, ill health or damage to property. This includes events occurring in a person’s own home where we are providing care or support. 8.2.  Incident: Any event or circumstance arising during the provision of care or support that led to, or could have led to, harm, loss, damage or disruption. This includes clinical and non-clinical incidents, safeguarding concerns, medicines incidents, falls, errors or omissions in care, and any use of restraint or restrictions. 8.3.  Near miss: An unplanned event that did not result in harm, loss or damage, but had the potential to do so. Near misses are treated as learning opportunities and must be reported and reviewed in the same way as incidents. 8.4. Notifiable safety incident (Regulation 20): For non-NHS providers, an unintended or unexpected incident occurring during a regulated activity that, in the reasonable opinion of a healthcare professional, appears to have resulted in or requires treatment to prevent: death; an impairment of sensory, motor or intellectual functions lasting ≥28 days; changes to body structure; prolonged pain or prolonged psychological harm; or shorter life expectancy. Near misses (where no harm results) are not in scope for notifiable safety incidents under Regulation 20, but they must still be recorded, reviewed and used for learning. 8.5. CQC statutory notification (Care Quality Commission (Registration) Regulations 2009): Incidents that must be notified to CQC without delay, including death of a person using the service (Reg 16) and, under Reg 18, serious injury, abuse or allegations of abuse, incidents reported to or investigated by the police, and events that stop a service running safely and properly. 8.6. RIDDOR reportable incident: Events that meet HSE thresholds (e.g., death, specified injuries, over-7-day incapacitation, certain dangerous occurrences, occupational diseases, and non-worker injuries where taken directly to hospital for treatment). Further detail on what must be reported under RIDDOR and example scenarios relevant to domiciliary care (including injuries to people using the service in their own homes) can be found in HSE guidance (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013). ## 9. Reporting and Documentation Procedures 9.1. To ensure accountability, transparency and learning, all accidents, incidents (including safeguarding concerns, medicines incidents, falls, errors or omissions in care, and any use of restraint or restrictions), and near misses must be:- - a. Reported immediately to a supervisor, manager, or designated safety officer. - b. Recorded in the Incident Report Log with details including date, time, location, individuals involved, and nature of the event. - c. Escalated to external authorities (e.g., RIDDOR, CQC) if required by law. - d. Subject to an initial management review within 24 hours to determine immediate actions, risk level, whether external notifications (for example, safeguarding, CQC, HSE) are required, and any urgent support for the person affected and staff. - e. Logged in a way that allows analysis of trends over time (for example, by type of incident, time, location, person affected, staff involved), to support learning and improvement. - f. Where restraint or restrictive practices have been used, ensure that the incident record clearly describes the circumstances, rationale, type and duration of restraint, de-escalation attempts, the person’s views (where possible), and any injuries or distress, and that this information is used to review care plans and risk assessments in line with Regulation 13 and human rights principles. ### 9.2. External notifications and time limits 9.2.1. Notify CQC without delay, and in any case as soon as reasonably practicable after the event or after becoming aware of it, using the current statutory notification forms or Provider Portal when applicable: death (Regulation 16); serious injury, abuse/allegations of abuse, incidents reported to or investigated by the police, and events that stop the service running safely and properly (Regulation 18). For domiciliary care this includes incidents occurring in a person’s own home where the incident arises out of or in connection with the carrying on of the regulated activity. 9.2.2. RIDDOR to HSE:- - a. Submit reports online (telephone available only for fatalities/ specified injuries). - b. Within 10 days for most reportable accidents; within 15 days for over-7-day incapacitation cases; without delay for deaths/specified injuries. - c. Members of the public: report if injured due to work activity and taken directly to hospital for treatment. 9.2.3. Safeguarding: Where criteria in Care Act 2014, Section 42 are met, raise a safeguarding concern with the local authority (and the police where a crime is suspected), following local safeguarding adults board procedures. Cooperate fully with any Section 42 enquiry and multi-agency meetings and record outcomes and actions clearly in the person’s care records and incident file. 9.2.4. Records: Keep RIDDOR records for at least 3 years (retain longer if local policy or litigation risk requires). 9.2.5. Commissioners and contract monitoring: Where required under local authority, Integrated Care Board or other commissioning contracts, ensure incidents, serious events and safeguarding concerns are reported to commissioners in line with contractual timescales and formats, and that any resulting action plans are implemented and monitored. ## 10. Investigation and Root Cause Analysis 10.1. Every reported event undergoes an immediate risk assessment and a proportionate investigation, following the steps below. The depth of investigation (for example, brief review, structured investigation or multi-agency review) will be matched to the level of actual or potential harm and complexity. 10.2. Step 1: Gather Information:- - a. Collect witness statements and photographic evidence (if appropriate). - b. Interview affected individuals to understand the context. - c. Involve the person affected, and where appropriate their family or representative, in describing what happened and what matters most to them following the incident. 10.3. Step 2: Analyse Causes:- - a. Identify direct and underlying causes of the event. - b. Determine whether failure of equipment, human error, or environmental factors contributed. - c. Where appropriate, use a structured method such as a “5 whys” analysis or similar human-factors approach to understand why defences failed and to avoid attributing blame to individuals without considering system factors. 10.4. Step 3: Implement Corrective Actions:- - a. Immediate control measures to prevent recurrence. - b. Long-term improvements such as staff training or policy revisions. - c. Agree who is responsible for each action, timescales for completion, and how completion and effectiveness will be checked. 10.5. Step 4: Duty of candour (Regulation 20) - a. When an event meets the notifiable safety incident threshold, we will identify the “relevant person” (usually the person using the service, or where they lack capacity or have died, their representative) and inform them as soon as reasonably practicable. We will offer a sincere apology, explain what is known at the time, outline next steps in the investigation, and provide this information in writing. - b. We will provide written updates as new information emerges, explain what actions we are taking to reduce the risk of recurrence, and give the relevant person an opportunity to ask questions or share their views. - c. All duty of candour communications, including attempts to contact the relevant person, apologies, meetings, letters and actions taken, will be documented in the incident file and the person’s care record, and retained in line with our records management policy. 10.6. Step 5: Documentation and Review - a. Maintain records for compliance audits and safety improvements. - b. Share relevant findings and learning with staff to enhance safety awareness and, where appropriate, with people using the service and their families/representatives so they know what has changed as a result of incidents and feedback. - c. Feed learning from incidents and near misses into supervision, team meetings, training, policy reviews and the governance cycle, and record evidence of changes made and re-audits. - d. Incorporate learning and recommendations from external investigations and reviews (for example, Section 42 enquiries, Safeguarding Adults Reviews, CQC inspections and commissioner reviews) into our improvement plans and monitoring processes. ## 11. Preventative and Corrective Actions 11.1. To reduce the likelihood of recurrence, preventative actions include:- - a. Staff training on safety protocols and risk awareness. - b. Regular risk assessments and safety audits in domiciliary settings. - c. Equipment maintenance and safety checks for assistive devices. - d. Encouraging open reporting culture to identify potential hazards before they escalate. - e. Embed a learning culture consistent with the CQC Single Assessment Framework: systematically analyse events, share lessons with staff and people using services, and evidence resulting changes. - f. Periodically verify equipment, environment and staffing controls align with Regulation 12 (Safe care and treatment) risk requirements. - g. Carrying out and regularly reviewing person-centred risk assessments in people’s homes (for example, for falls, moving and handling, fire safety, mobility aids, use of bedrails and assistive technology), involving the person and, where appropriate, their family and other professionals. - h. Implementing safe medicines management practices in domiciliary settings, including prompt reporting and review of any medicines errors, omissions or near misses, and ensuring learning is shared and actions taken. - i. Use incident and near miss data, including trend analysis and human factors insights, to inform service design, staffing, training, supervision and equipment decisions, and to monitor whether changes have led to measurable reductions in harm or risk. 11.2. Corrective actions following an incident may involve:- - a. Policy or procedural changes to enhance workplace safety. - b. Environmental modifications (e.g., improved lighting, slip-resistant flooring). - c. Additional supervision or refresher training for staff. - d. Reviewing and, where necessary, revising individual care and support plans and risk assessments with the person and relevant professionals following an incident, ensuring their views and preferences are reflected in any changes. ## 12. Compliance Monitoring and Continuous Improvement 12.1. To maintain high safety standards and demonstrate continuous improvement under the CQC Single Assessment Framework, The Good Place:- - a. Conducts at least quarterly reviews of accidents, incidents, near misses, complaints and safeguarding concerns at management / governance meetings to identify trends, themes, learning and required improvements. - b. Implements corrective measures based on investigation findings. - c. Engages with staff and service users for safety feedback and improvement suggestions. - d. Regularly updates this policy in response to regulatory changes and best practices. - e. Ensures that actions arising from incident reviews are captured in a service improvement or quality plan with named leads, timescales and evidence of completion and impact. - f. Shares appropriate learning with people using the service, families and staff (for example, via newsletters, meetings, training and one-to-one discussions), and records how feedback has influenced changes. - g. Uses incident data and learning as part of evidence submitted to CQC (for example, through Provider Information Returns and on inspection) to demonstrate a positive safety culture and continuous improvement. 12.2. We benchmark incident management against relevant CQC Single Assessment Framework quality statements, including Safe (Learning culture, Safeguarding, Involving people to manage risks, Safe environments), Effective (Delivering evidence-based care and treatment, How staff and teams work together), Responsive (Listening to and involving people) and Well-led (Governance, management and sustainability; Learning, improvement and innovation). We also consider the associated evidence categories (for example, people’s experience, feedback from staff and leaders, processes and outcomes) and track actions and outcomes through our governance cycle. We value your privacy We sometimes use a number cookies to improve your browsing experience, but these are not always essential to the propper functionality of our site. By clicking "Accept All", you consent to our use of these additional cookies where applicable. You can read more about cookies in our [Website Privacy Statement](https://www.thegoodplace.care/policies-and-procedures/website-privacy-statement).