1. Notifiable Events
The following should be notified without delay to the Care Quality Commission (CQC) in relation to an adult receiving care and support from the service:
- incidents reported to the police;
- allegations of abuse in relation to the adult;
- applications to deprive an adult of their liberty under the Mental Capacity Act 2005 including date, details of urgent deprivations, outcomes and withdrawals (see Deprivation of Liberty Safeguards);
- medication errors are not a formal notification except in the case of where this causes injury or harm to the adult. However for best practice refer to the local inspector and CQC as to whether a medication error needs to be formally reported to them. If the local safeguarding adults team has been notified, this should be reported to CQC;
- death or unauthorised absence of an adult detained or liable to be detained by the Mental Health Act 1983 (see also Notification of Death of an Adult who uses the Service; this may not apply to all services);
- injuries include those that lead to or that, if untreated, are likely to lead to permanent damage, or damage that lasts, or is likely to last, more than 28 days, to:
- a person’s sight, hearing, touch, smell or taste;
- any major organ of the body (including the brain and skin);
- muscles, tendons, joints or vessels;
- the development after admission of a pressure sore of grade 3 or above, which develops after the person has started to use the service.
- changes to the structure of the body;
- prolonged physical pain or psychological harm;
- shortened life expectancy;
- injury that may lead to death or any of the outcomes listed above;
- insufficient number of suitably qualified, skilled and experienced staff;
- changes to a Statement of Purpose;
- interruption in the supply to premises of electricity, gas, water or sewerage for longer than 24 hours continually (this does not apply to domiciliary care services, although action needs to be taken to remedy the situation if this occurs in the property were an adult service user is living);
- physical damage to premises which has, or is likely to have, a detrimental effect on the treatment or care provided to service users;
- failure or malfunctioning fire alarms or other safety devices for longer 24 hours continually.
Notifications about an incident affecting a person will include:
- a unique identifying code (not their name), their date of birth, gender, ethnicity, any disability, any religion or belief, sexual orientation;
- the date upon which they were admitted to the service;
- all relevant dates and circumstances;
- anything already done about the incident.
Please note: for supported living / domiciliary care services, this only applies if it involves a service user in receipt of personal care. However, in the event of any doubt or need for further clarification it is recommended that this is clarified by the manager of the registered service, with the local inspector in respect of personal care / domiciliary cares. Notification will be made to the CQC if the registered manager is expected to be absent from the service for more than 28 days, stating the arrangements which will be in place during the absence. If the absence is planned, notification must be made 28 days in advance; if unplanned, within 5 days of the absence commencing.
Any change in the registered manager, the registered manager’s or the service details or the ownership will be notified to the CQC as soon as reasonably practicable. Registered managers are responsible for deregistering with the CQC before they leave their employment with the service. A new application will be sent to the CQC as soon as another registered manager is confirmed in post. Records of notifications to the CQC will be kept for three years. The registered manager will be aware of the procedure for notifying the placing authority of any serious concern about the emotional or mental health of the service user and actions required to request a mental health assessment under the Mental Health Act 1983.
2. Who should be Notified of Significant Events
Service managers or delegated others are responsible for notify relevant agencies, regulators, family members and senior managers internally within 24 hours or sooner of significant events (please see On Call Rota). Formal notifications will be made to the local authority, the Care Quality Commission, the placing authority and family members (if given consent by the individual). Where legal orders are in place to restrict contact with family members, notifications will be solely made to regulators and the placing authority.
The Care Quality Commission own forms for notification of significant events should be completed and emailed to the CQC within agreed time frames (see CQC Notifications).
Any incident / accident or near miss (whether notifiable to CQC or other body, person) must be reported by the completion of an incident / accident form by the staff member involved in the incident. This should be completed and signed by the person as soon as possible after the event and certainly within 24 hours of the incident. The manager should review the incident, implement risk management changes if required and sign the form. Senior managers of the service should be notified as appropriate. In the case of a major incident (see Section 1, Notifiable Events) this should be reported immediately following the incident.
3. Reporting Certified Treatment
The Mental Health Act requires that, where a patient has received treatment certified by a panel or a Second Opinion Appointed Doctor, a report on the treatment and the patient’s condition must be given by the approved clinician in charge of the patient’s treatment to the Care Quality Commission.
These reports are required generally when a patient’s detention is renewed (for patients subject to a Community Treatment Order this report is only required at the renewal of the order if they have received treatment certified by a SOAD when recalled) following a second opinion or when the Care Quality Commission requires one.
4. Action Following a Notification
Following a notification, the registered manager where required will meet with the adult, representative/s of the placing authority and family members to review the incident and actions resulting from any post incident investigation. Further actions will be agreed and appropriate changes made to the adult’s care and support plan.