Incident Report

Incident Log No:

- Strictly Private & Confidential -

ALL incidents must be immediately reported to your line manager or another appropriate manager such as service manager, the local on-call, or head office out of hours.

As soon as possible following an incident, and within 24 hours at the latest, an incident report must be completed and sent to the relevant local manager(s). This must be concluded within 48 hours of the incident occurring (or the next available working day after 48 hours).

The incident report should be completed by the person with the most first-hand knowledge – ie. The person involved in the incident or the person witnessing an incident. They should complete sections 1-4 of this report. Manager to complete section 5.
Section One – Details of the Incident

Name of Service:
Date & Time of Incident:	Date:	Time:
Description of the Incident (Eg. “Medication Error – Missed Dose”)
Name & Role of Person Completing Report:	Name:	Role:
Date & Time Report Completed:	Date:	Time:
Name & Date of Birth of Service User(s) Involved:	Name:	DOB:
Name:	DOB:
Name:	DOB:
Name & Role of Staff Member(s) Involved:	Name:	Role:
Name:	Role:
Name:	Role:
Precise Location Where Incident Occurred:

Section Two – Details of the Service

Full Address:
Service Contact Number:	Cost Code:
Service Type:	Client Group:
Project Manager / Coordinator / Team leader:
Registered / Service Manager:
Service Director:

Section Three – Please provide a full factual and objective (not opinion-based) report of the incident and actions taken
(Your account should include details of what happened prior to the incident, the incident itself and any follow up action taken. Please report events in the order that they happened. Where names are mentioned please state the role of the person. Continue on a separate sheet if necessary and attach)

Section Four – Immediate Follow Up Actions & Reporting

If you have not yet reported this incident to a manager please do so now. If a manager is not available locally please call your local on-call or head office on 0161 236 0829
Name of Manager Reported To:
Role:	Method (Eg. Phone call):
Please detail what advice or instructions they gave and/or what action they and you took:
Medical Advice Sought:	YES / NO	Details / Actions / Outcomes:
Ambulance Called:	YES / NO	Details / Actions / Outcomes:
Reported to Police:	YES / NO	Details / Actions / Outcomes:
Next of Kin Informed:	YES / NO	Details / Actions / Outcomes:
Safeguarding Team Notified:	YES / NO	Details / Actions / Outcomes:
Social Worker / Adult Social Care Notified:	YES / NO	Details / Actions / Outcomes:
Any other agency/service or person informed:	YES / NO	Details / Actions / Outcomes:
Additional Notes / Comments about the incident and follow up actions:

Section Five – Management Follow-Up and Feedback.

Manager Completing Follow Up:	Date:
Are you satisfied with the immediate follow up to this incident:	YES / NO	Comments:
Could this incident have been avoided/prevented:	YES / NO	Comments:
Can this incident be attributed to one or more members of staff?	YES / NO	Comments:
What was done well: Please feed this back to the staff involved
What was not done well / could be done better: Please feed this back to the staff involved
Who Was (Or Will Be) Informed Of This Incident: (Please tick all that apply)
Service Director:	Local Authority Safeguarding Team:	Social Worker / Adult Social Care Team:
Care Quality Commission (CQC):	Police:	Family / NOK Informed:
Housing Team / Landlord Informed:	Health & Safety Team Informed:	Internal Auditing Team Informed:
Creative Support Customer Care Team:	Information Shared With Local Services / Colleagues / On-Call:	Other (Please specify):
Further Actions Taken or To Be Taken Following This Incident: (Please tick all that apply)
Additional Care Provided: (Interim Measure to reduce risk)	Additional Care Requested Permanently:	External Review: (Local Authority, Mental Health, CHC etc)
Internal Review:	Support Plan Reviewed/Updated:	Risk Assessment Reviewed / Updated / Implemented:
Additional Monitoring Forms Introduced:	External Referral: (Eg. Falls Team, OT, Mental Health Team)	SU Medication Review:
Internal PBS Referral:	Manager’s Audit / Check Completed:	Supervision with Staff:
Staff Direct Observation:	Post-incident debrief / welfare follow up (Including HR Involvement):	Staff Investigation:
Staff Member Suspended:	Performance Management Plan:	Training Course for Staff:
On-the-job Training / Coaching for Staff:	Staff Memo/Communication Issued:	Discussion in Team Meeting:
Staff/SU Compatibility Reviewed:	RIDDOR Notification:	Other (Please Specify):
Additional Notes / Comments / Actions Regarding the follow up and outcome of this incident:

Once this page is completed please send the concluded incident report to incidents@creativesupport.co.uk