Incidents Guidance

Contents

1. Definition of Incident
2. Notifications
3. Incident Recording
4. Manager / Senior Practitioner Responsibilities
5. Management Reviews

1. Definition of Incident

The following are defined as incidents, but this list is not exhaustive. Any similar occurrences can be defined as an incident by a manager, and recorded as such:

• Physical assault or violence caused to a young person or member of staff/carer;
• Injury, of a serious nature, caused to a member of the public by a young person or staff/carer;
• Accident, of a serious nature, caused to a member of the public, young person or staff/carer;
• Barricading by a young person resulting in forced entry by staff/carer or the Police;
• Damage, of a serious nature, caused maliciously or non-accidentally;
• Illegal access/possession of controlled drugs or substances;
• Self-harming, of a serious or persistent nature;
• Suicide, attempted suicide or death of a young person;
• Searches of a young person or a young person's belongings without the young person's permission;
• Bullying, of a persistent or serious nature;
• Physical Intervention (including Restraint) upon a young person;
• Police or other emergency services being notified or attending an incident.

2. Notifications

If an incident occurs, the manager or deputy manager must be notified as soon as practicable but at the latest within 24 hours. The young person’s social worker must also be informed within 2 working days.

The social worker and team managers will ensure that all significant events that are potentially life threatening are immediately notified, via the full line management route, to the relevant Heads of Service. This should be done verbally in the first instance and followed up in writing as soon as possible.

In some circumstances, other agencies must also be notified. See: Notification of Serious Events Procedure.

3. Incident Recording

3.1 Which records must be completed?

The following records should be completed after an incident:

Any incident involving a restraint must be recorded. It should be noted in the relevant young person's residential notes on Mosaic and records of the incident completed in detail on a CF50a form.

Any other incident must be recorded in detail on the relevant young person's residential notes on Mosaic.

3.2 When to complete the records

Unless stated differently records pertaining to incidents must be completed within 24 hours.

However, it is advisable that staff do not complete records immediately after an incident, but wait until they can calmly recollect what happened.

If an incident leads to, or is followed by, the absence of the person responsible for completing records due to leave, sickness, rest days, it is normally reasonable to expect that person to complete the records before leaving. If exceptional circumstances, such as hospitalisation, prevent this from happening, the senior practitioner on duty or manager must arrange for the records to be completed as accurately as possible in another way.

Before completing records, it may be helpful 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.

3.3 Who should complete the records?

The staff member most significantly involved should complete the records, after consulting other staff concerned; except where there is any risk that a complaint, or Section 47 Enquiry/criminal investigation will be made, in which case each person involved must write their own record.

Separate records must also be completed if there is significant difference or dispute between staff about what occurred.

3.4 Guidance on completion of incident records

1. Write down what happened in chronological order, preferably stating the time each event occurred;
2. Don't express opinions and don't make assumptions about what happened;
3. 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;
4. Differences of opinion, recollection or knowledge must be accurately recorded;
5. Avoid using jargon or professional terms unless you are confident that readers will understand them;
6. Don't use generalisations such as "aggressive", "verbal" or "offensive"; use plain English, write down exactly what was said or done, and by whom;
7. Always use full names. If the common name for a person is an alias or nickname, always put the persons full name in brackets the first time you use the alias;
8. Always indicate, in brackets, the status of the person named (e.g. residential practitioner or young person);
9. State clearly what diversionary tactics or strategies were used, and by whom; also state the impact or changes the tactics brought about;
10. If Physical Intervention was used, state the name of the technique used; if the technique has no name, describe the intervention rather than saying "He was held or restrained";
11. Also state who used the intervention, the duration it was used and what was said and done during the intervention until the young person was released;
12. If more than one intervention was used, state the order they were used in - and why it was necessary to escalate or reduce the intervention;
13. If there are particular techniques used give their technical names and say in what order they were used;
14. The young person should be asked to contribute to the report(s); as part of this process where appropriate, the young person should also be offered an interview again where appropriate. If requested, if there is a significant difference between the views of the staff and the young person or a complaint is made, an independent person must offer support to the young person and obtain their views/comments;
15. Complete all sections. 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;
16. 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 or Deputy as soon after the incident as possible. If you feel uncomfortable or uneasy about returning to work also talk to a manager.

4. Manager / Senior Practitioner Responsibilities

4.1 Prevention of Incidents

1. Senior Practitioners must ensure staff are familiar with relevant procedures; using creative and interesting methods to bring procedures to their attention, discussing them in supervision sessions and meetings, undertaking role plays etc.
2. If procedures appear to require updating or amendment, including the way in which incidents are recorded, the matter must be followed up with line management;
3. Staff are required to do all they can to contact management if they anticipate an incident or immediately afterwards if they did not. If, for whatever reason, managers are not likely to be available, they should ensure suitable contact arrangements are in place, that a colleague has been identified to provide cover or that individual staff understand the levels of their delegated authority;
4. If a member of the management team anticipate that an incident may occur, they must plan to reduce or prevent the risks, and they must inform staff via the most suitable communication route;
5. Staff must inform the Senior Practitioner on duty or Manager that they suspect or anticipate an incident, they must be taken seriously and provided what appropriate levels of support, guidance and direction to manage situations safely;
6. If managers anticipate a serious incident that may require intervention by the Police or other emergency services, consult or inform those agencies;
7. Also consult relevant social workers;
8. Keep accurate records of your contacts, conversations, decisions and actions.

4.2 Immediate Management Responsibilities

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, regardless of whether the young person has been or appears injured, they 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 judgments or take sides;
• Ensure that the young person is given adequate opportunity to contribute to the reports, consider whether the young person would benefit from discussing the incident with an advocate;
• Establish whether people need to be separated, for example if there are complaints; and take what action is necessary;
• Ensure those involved are recording their recollections in detail in any report. If 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 24 hours of the incident;
• If there are complaints or any potential child protection issues, follow them up in line with appropriate complaints or the West Yorkshire Consortium Safeguarding and Child Protection Procedures;
• Arrange for social worker, parents and others, including Designated Managers and others to be notified.

5. Management Reviews

5.1 Purpose of the Management Review

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 young people alike, will have been affected, probably negatively; some may have been traumatised.

Don't look to catch people out, seek to help people learn from what has happened.

Take a positive, developmental stance throughout, even if things could have been done differently.

5.2 Who should undertake the review?

The manager should undertake the review, unless directly involved or as required by a line manager.

5.3 Timescales

Under normal circumstances, the Registered Manager or Deputy Manager must review the incident within the following timescales:

• Restraints: Within 72 hours of the restraint report (CF50a) being completed by staff;
• All other Incidents: Within 5 days of the Incident Report being completed by staff.

If there are Police enquiries, Section 47 Enquiry or complaints investigations, the review should be postponed until they are complete.

5.4 Gather Information

1. Don't make judgments 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 young person, at all stages - inform them of the anticipated timescales;
4. Listen, note, explore; try to identify the circumstances or behaviours which 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 young person (or staff) set up by the actions of others; did anyone act in a way which 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 young person, whether or not the young person 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.

5.5 Consider Information

1. Remain objective, stay positive and look for developmental outcomes. Only consider any sanctions or disciplinary measures as a last resort;
2. Balance what actually happened against what was required by procedure and protocol, recognised good practice or in the light of staff experience, skills and knowledge;
3. Consider how the young person acted in the light of their 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 / area of authority are required;
6. Consider whether there are 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 young person's Placement Profile/Placement Agreement or Plan; ICMP; Risk Assessment; 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 - which 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 young person's Placement Agreement or Plan, the manager must coordinate these changes.

5.6 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. 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. Ensure that a wider debrief takes place in full team meeting with group discussion / hypothesis of the situation for reflective practice. 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 young person 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 in all identified locations.