1.3.9 Incidents Management and Reviews

Contents

1. Introduction 
2. Reporting Incidents
3. Records and Forms
4. Management Responsibilities

1. Introduction

This guidance is designed to assist staff on reporting incidents and the completion of Incident Reports, and Managers in the undertaking of Management Reviews.

This Chapter should be read in conjunction with relevant incident procedures, e.g. Countering Bullying Procedure, which defines an Incident as any persistent or serious bullying.

Some incidents are also Notifiable Events, such as Death of a Child.  Notifiable Events Procedure contains a list of what constitutes a Notifiable Event and summarises the steps that must be taken in such an event.

2. Reporting Incidents

Unless otherwise stated in relevant procedures, Incidents must be reported to the Resource Manager and relevant social worker(s) without delay. 

Without delay means as soon as practicable but within 1 working day.  Where an agency is not open for business, e.g., at weekends, it is reasonable to notify them on their next working day.  Social workers should also be notified when their offices are open for business unless it has been agreed that their Out of Hours or Emergency Duty Teams can be contacted.  In any case, social workers must also be notified when their offices re-open.  If social workers are not available, their Line Managers must be contacted.

Where the Resource Manager is unavailable, his/her Line Manager must be informed and then the Resource Manager notified when practicable.

It will be for social workers to decide whether to notify parent(s).

3. Records and Forms

Which records/reports must be completed?

When an incident occurs, whether notifiable or not, it must be recorded.

An Incident Report must be completed, as well as the Report Log Book, Daily Log and relevant young people's Daily Summary sheets.  Other records will also be completed, as required by relevant procedures.

If a Notifiable Event occurs, the Resource Manager must complete a Schedule 5 Events and Notifications Record and forward it to the Regulatory Authority.

When to complete records/reports

Care Standards require that Incident Reports be completed as soon as practicable after incidents have occurred, but within 24 hours, which probably means 1 working day.

It is advisable that staff do not complete records immediately after an incident, but wait until they can calmly recollect what happened.  If unable to do so (e.g. too traumatised), staff should seek permission from a Manager to extend the timescale.  However, it is recommended that rough/handwritten notes are made as soon as possible after the event to ensure clarity.

Staff must not destroy rough/handwritten notes when the final report is completed, they should be kept safe.

Before completing records, it may be helpful for staff to talk to others involved to help recollect events, but staff should avoid having suggestions put to them that are inaccurate or inconsistent with what they did or observed. Any disagreements or different perceptions must be included.

Who should complete records/reports?

The staff member most significantly involved should complete records, after consulting other staff concerned; except where there is any risk that a Complaint, Child Protection Enquiry or criminal investigation will be undertaken.  In which case, each person involved must write his or her own record.  Separate records must also be completed if there is significant difference or dispute between staff on what occurred. (See Representations and Complaints Procedure)

Guidance on completion of reports

A sample Incident Report and guidance is included in 'Sample Incident Report'

1. State the day as well as the date and time of the incident.  State your own name, preferably in capitals, and state your Post Title.
2. When asked for locations, be as clear as possible (don't just say "On the Stairs", say where e.g. toward the top or bottom).
3. Write down what happened in chronological order, preferably stating the time (or approximate time) each event occurred.
4. Use the 24 or 12 hour clock consistently throughout the report.
5. Don't express opinions and don't make assumptions about what happened. 
6. If you are writing the report on behalf of others make sure you check and report their versions, not what you think they said or did. 
7. Differences of opinion, recollection or knowledge must be accurately recorded; significant differences or disagreements must be recorded separately.
8. Always use full names.  If the common name for a person is an alias or nickname, always put the person's full name in brackets the first time you use the alias e.g.  Dave (David) Smith
9. Always indicate, in brackets, the status of the person named (e.g. Foster Carer, RSW, Young Person)
10. Avoid using jargon or professional terms unless you are confident that readers will understand them.
11. Don't use generalisations such as "aggressive", "verbal" or "offensive"; use plain English, write down exactly what was said or done, and by whom.
12. State clearly what diversionary tactics or Strategies were used, and by whom; also state the impact or changes the tactics brought about.
13. If Physical Intervention was used, provide a justification, e.g. that it was necessary to intervene to prevent the child or others from being injured.  If injury was likely, state the potential or actual severity.  Note: Restraint, which is the positive use of force with the intention of overpowering a child, may not be used at any time unless it is necessary to prevent Significant Injury or Serious Damage to property. 
    
    If Physical Intervention was used, state the name of the technique used; if the technique has no name or is not approved, describe the intervention rather than saying "He was held or restrained". 
    
    Also state who used the intervention, the duration it was used and what was said and done during the intervention until the child was released. 
    
    If more than one intervention was used, state the sequence they were used in - and why it was necessary to escalate or reduce the intervention.
14. The child should be asked to contribute to the report(s); as part of this process, the child should also be offered support or counselling.  If requested, if there is a significant difference between staff and child versions or a complaint is made, an Independent Person must offer support to the child and obtain his/her views/comments.
15. If Restraint or other Physical Interventions were used, state whether the child was offered support or counselling; if so, by whom and summarise outcome.  Also state whether the child or others were offered medical attention, whether it was accepted and the outcome.
16. If completing a form/record, don't leave sections blank or any significant spaces.  If you have nothing to report in a section, either draw a line through it, put N/A or (for example, in the section on injuries) "No Injuries".  Alternatively strike a line through the space.
17. Always sign and date the record and make sure other staff do the same before you pass it to the Manager.

If you have any concerns about your own or other people's actions or decisions you must discuss them with the Manager as soon after the incident as possible.  If you feel uncomfortable or uneasy about returning to work also talk to a Manager

SAMPLE INCIDENT REPORT

This is an example of how to fill in a Physical Intervention/Incident Report in the duplicate book.  This should be read in conjunction with Guidance on Completion of Reports above

Name:	Shama Ahmed
Date:	27th February 2003
Time:	13:10 hours
Resource:	Primrose Cottage
Location:	Kitchen
Report By:	Sally Smith (RSW)
Other Staff Present:	Jo King (Team Leader)
House Number:	PC0001
REPORT
A - Antecedents to Incident Specify where the incident started, or initially developed from. Clarify the whereabouts of all staff and young people. Put incident into a context of what would ordinarily be happening i.e. about to go to school or bed etc. Include the 'environmental climate' i.e. was there tension from other residents, visitors, or staff etc. State what the actual developing conflict was about. I.e. Refusing to go to school etc. Begin to include your points of discussion with the young person. Make reference to how previous similar situations with this particular child can develop (based on their risk assessment) but do not take or suggest 'routine' action
B -  Behaviour What other methods have been used and have they been exhausted? Detail any Strategies / skills that were used prior to resorting to physical intervention? - "Asked to stop - used Humour etc. Record any explanations used with the young person - "I don't want to hold you but if you continue then....." Detail how your knowledge of the young person's profile/history may impact on your decision making What risk was the immediate presenting risk? Record the reason that Physical Intervention was necessary. i.e. to prevent injury to self or others or serious damage to property (but state only which ones apply, not all three!) State clearly all holds used and which member of staff was on which side i.e. left or right of the young person. What risk would there be if no physical intervention takes place?
C -  Conclusion of Incident Detail how the incident de-escalated Include factors that contributed to the ending of the incident Refer to dialogue used that assisted in bringing the incident to a close Record any views of the child during the de-escalation process Include evidence of a caring response to the child, e.g. words of re assurance, and empathy of their situation
Duration of Incident:	40 minutes
Duration of Physical Intervention (If applicable):	5 minutes
Any injuries sustained to Young Person:  Record Details (If none state None).  Ensure skin map is completed and attached to the report if necessary.  If first aid or medical attention is required, give full details. (Ensure accident book is appropriately completed).
YOUNG PERSON'S COMMENTS: Record in detail the young person's comments, if no comment, state so.  Need young person's comment, name, signature and date. Any complaints?
INDEPENDENT PERSON'S COMMENTS:  Who can be an Independent Person? Preferably Senior RSW's, Team Leaders & Managers. If circumstances dictate then it is acceptable for an experienced RSW to complete this role, however they must fully understand the importance of the role and be aware of their responsibilities in regard to complaints, practice issues and the Child's welfare. Need to make appropriate comment, print name, sign and date. Record conversations/discussions held with child or others that were involved or present. Talk through what has happened, what could the child have done differently, what could the staff have done differently and record. Consider effectiveness, this includes reviewing, discussing and responding to interventions (refer to specific guidance)
NOTIFIED Please ensure all of the below is completed State YES, NO or N/A and give details, i.e. whom and times. Parents - State date parents contacted (If applicable) Authority - State name of SW and date contacted Group/Assistant Group Manager - State name of Manager and date contacted On Call Manager - State name of Manager and date contacted Sanction Imposed - Record detail, including all earn back facilities Ensure that the young person either reads or has the report read to them within 24 hours of the incident, and that they sign the record or staff annotate the record if the child refuses.
FURTHER ACTION Record further action required, Manager can comment on discussions held surrounding the incident. Further action to be used as a 'Signpost' to other areas, subsequently producing a 'paper chain' that can be followed for more information, i.e. Complaints, practice issues, notifications etc. Detail any issues for Regulation 34 and Review of Quality of Care Meetings.

4. Management Responsibilities

Immediate Post Incident Responsibilities

This summarises the Manager's responsibilities, post incident.

The Manager should also conduct a Management Review, see, The Management Review (Purpose of)

When the Manager is informed that an incident has occurred, the following tasks should be undertaken immediately:

• Co-operate with Police/emergency services if contacted; or consider whether the Police or other emergency services should be contacted.
• Check if anyone has been injured; ensure first aid or hospital treatment as appropriate.
• If Physical Intervention has been used, whether or not the child was injured, s/he must be given the opportunity to see a Registered Nurse or Medical Practitioner - and the outcome recorded.
• Check whether there is any damage; and that it is made safe or repaired
• Listen to everyone involved, note what they have said, provide support and advice if necessary; but don't make judgements or take sides.
• Ensure that the child is given adequate opportunity to contribute to the reports, consider whether the child would benefit from discussing the incident with an Advocate; if Physical Intervention has been used, offer the child support or counselling if appropriate.
• Provide support for the child and those staff involved - see Debrief and Support
• Establish whether people need to be separated, for example if there are Complaints; and take what action is necessary. (See Representations and Complaints Procedure).
• Ensure those involved are recording their recollections in detail in an Incident Record.  If there are any conflicts between those involved or potential complaints, ask each person to write a separate record.  These records should normally be completed and passed to the Manager within 1 working day of the incident.
• If there are complaints or any potential child protection issues, follow them up in line with appropriate complaints or Child Protection Procedures (See Child Protection Referrals Procedure)
• Ensure social worker, parents and others, including Senior Managers, are notified as required.  If a Notifiable Event has occurred, ensure relevant agencies are notified; see Notifiable Events Procedure

Managing child/staff relationships

It is possible that the children and staff involved will be emotionally traumatised as a result of the incident.  Therefore the Manager must ensure that steps are taken to assess and repair any possible damage - or should seek specialised help to do so.

As soon as possible after the incident, at a time when the child and others involved appear responsive, the Manager should arrange a meeting with them, either individually or in a group.  The purpose of this meeting is to:

• explore what happened, from everyone's perspective
• encourage people to take responsibility for their actions
• seek/agree alternative behaviours/strategies for the future

This should be undertaken in a culture that is supportive, even if people could have behaved differently.

If Physical Intervention was used, the Manager must review the extent to which the techniques used were appropriate, or whether staff require additional training or advice.  If so, this must be provided.

The management review (purpose of)

See also Review of Quality of Care Procedure

The purpose of the Management Review is to unpick the circumstances leading to the incident, the manner in which it was managed and the actions and decisions of all those involved - with a view to reducing or preventing future similar incidents.

As a last resort it may be necessary to reprimand, sanction or take other disciplinary measures against a person involved; but the review should never be conducted in the context of trying to blame those involved.

Everyone involved, staff and children alike, will have been affected, probably negatively; some may have been traumatised. 

Managers shouldn't seek to catch people out, they should seek to help people learn from what has happened; they should take a positive, developmental stance throughout, even if things could have been done differently. 

Who should undertake management reviews?

The Resource Manager should undertake the review, unless directly involved or required by a Line Manager or by the Quality Assurance Manager.

Gathering information for management reviews

When conducting the review, Managers should take account of the following principles:

1. Don't make judgements early on.  Don't take sides. 
2. Start from the point of view of seeking to learn from what has happened
3. Involve everyone, including the child, at all stages.  Inform them of the anticipated timescales.
4. Listen, note, explore; try to identify the circumstances or behaviours that triggered the incident.  Analyse the extent to which everyone adhered to procedures or recognised good practice; were people working effectively together, were they planning ahead, sharing information, doing what they could to anticipate and prevent the incident from occurring?
5. Read the records of the incident, clarify and challenge, if necessary, generalisations, assumptions, justifications etc.  Unpick and simplify jargon.
6. If Restraint or other Physical Intervention was used, ensure staff are able to demonstrate they applied it in keeping with procedures and guidance.
7. Did everyone appear to behave reasonably in the circumstances?  To what extent was the child (or staff) set up by the actions of others; did anyone act in a way that provoked or increased the likelihood of the incident?
8. Look beyond that which is stated in the record of the incident; what hasn't been included which should have been in the circumstances.
9. If anyone was injured, check and note the outcome of any first aid or medical treatment offered/given.
10. If Physical Intervention was used upon a child, whether or not the child was injured, check and note the outcome of any first aid or medical treatment offered/given.
11. Obtain views from everyone involved about whether the incident was managed as required by procedures or in line with recognised good practice. 
12. Consult and keep your Line Manager informed if required to do so, if the review is complex or potentially controversial or if you need assistance/support.
13. Evidence the whole incident, considering what was the impact for the staff and the young person.

Reviewing information

Having gathered the information, Managers should review what occurred.

1. Remain objective, stay positive and look for developmental outcomes.  Only consider sanctions or disciplinary measures as a last resort.
2. Balance what actually happened against what was required by procedure, recognised good practice or in the light of staff experience, skills and knowledge.
3. Consider how the child acted in the light of his/her background, skills, and knowledge.
4. Consider your own interests and needs; look at the role you played; or should have played; be open to criticism.
5. Get help if you need it; consult your Line Manager, especially if policy or other decisions outside your brief are required. 
6. Consider whether there is any training or other support mechanisms that ought to be put in place for staff - or for yourself.  Is there a need for specialist help, support or counselling?
7. Consult the social worker; consider whether any changes are required to the child's Placement Plan; including new or amended expectations, Strategies or interventions to help reduce or prevent the likelihood of a repeated incident. Is there a need for specialist or therapeutic help, support or counselling?
8. Come to a decision, which can be sustained - that can be put into practice.
9. Avoid 'punishing' or looking to blame.  Seek outcomes that are encouraging and developmental

If changes are required to the child's Placement Plan, the Manager must co-ordinate these changes; which may mean undertaking a Placement Review.

Debrief and support

Make sure everyone is informed of the outcome, and is given the opportunity to make comment.

Having undertaken the Management Review, the Manager must ensure that all concerned do not have unresolved feelings, guilt or other concerns about their own behaviour or other people.  Please see additional guidance below.

In some circumstances it may be necessary for the Manager to ask an independent consultant or counsellor to provide assistance; especially if there are indications of post-traumatic stress disorder.

The emphasis must be on everyone learning for the future - and reducing or preventing similar incidents from occurring.

It may also be appropriate for all concerned, including the child if it would be beneficial to meet and discuss what happened.

If there are procedural, policy or practice issues which individuals or whole teams can benefit from the Manager must follow them up.

The Manager must record the outcome.

End