Family Placement Service – Serious Incidents, Duty of Candour and Notifications to the Registration and Inspections Unit

The Family Placement Service (“FPS”) must report notifiable events in line with Regulation 10 of the Regulation Of Care (Care Services) Regulations 2013.

This policy and procedure should be considered and read in conjunction with:

• Manx Care’s Policy and Procedure for Incident Reporting, Investigation and Learning
• Manx Care’s Duty of Candour Procedure.

The FPS will ensure that all foster carers and adoptive carers (prior to order) understand what are legally defined notifiable events, and how to (prior to order) inform the Supervising Social Worker and where appropriate the child’s Social Worker of any serious event as defined below:

The SSW MUST immediately inform the Team Manager, who as Registered Manager for the service, MUST notify the Registration and Inspection Unit  within 24 hours.

1. The death of any service recipient at the care service and the circumstances of the death; this is a child or young person in placement;
2. The outbreak of any notifiable disease (within the meaning of Part II of the Public Health Act 1990) at the care service; For notifiable diseases, please refer to gov.im - Notifiable diseases. These include infections such as, Salmonella, Dysentery, Tuberculosis, Campylobacter and rubella;
3. The serious injury or illness of any service recipient at the care service; this is a clinical diagnosis of a child or young person with a life changing or life limiting injury or illness;
4. The suffering of serious harm of any service recipient at the care service, This will include, physical, sexual, financial matter, neglect/acts of omission, discriminatory, organisational, psychological/emotional and child sex exploitation;
5. Any event at the care service affecting the well-being of any service recipient. This would include, medication incident, attempted suicide/self-harm, misuse of drugs/alcohol, behavioural/well-being issue and estate issues (e.g. flooding);
6. Any unexplained absence of a service recipient from a care service; this means a child or young person whose goes missing;
7. Any serious incident necessitating calling the police to the care service;
8. The making of any allegation that a service recipient has committed an offence; if a child or young person has been arrested;
9. Any theft, burglary, fire or accident at the care service; and
10. Any conduct of a member of staff at a care service that may be such that they may not be a suitable person to be involved in the care of service recipients. Allegations or concerns are made against the foster carer or prospective adopter.

The Supervising Social Worker must then complete the Registration and Inspection Notification form (see Appendix 1: Registration and Notification Form) within 24 hours of the incident taking place. They must also notify the child’s social worker and team manager.

It will be the responsibility of the child’s Social Worker to inform parents and those with parental responsibility of the incident, where appropriate.

The Supervising Social Worker must forward the notification form to the Team Manager for approval.

The Team Manager will quality assure the notification form and will forward this on to the Registration and Inspection Unit. In addition, following a serious incident, the Team Manager must inform the Group Manager.

The Team Manager, Fostering Team Leader or Adoption Practice Lead will provide regular updates to R and I and the eventual outcome of any inquiry authorised by the Assistant Director of Children & Families.

All incidents and near misses must be reported via the Datix system.

This free text boxes of this report should not contain any personal identifiable information of children, carers or staff directly involved. The reporter will need to complete fields relating to Notification of Events to R&I and Duty of Candour. If in doubt, please seek advice from the Care Quality & Safety Lead for Social Care 686773.

Staff reporting an incident do not require a Datix login, however managers allocated to investigate and close down via Datix must have a login ID. This can be set up by the Care, Quality and Safety Team in Manx Care.

Any serious incident will be subject to investigation and the procedures relevant to the circumstances will be used to do this. A plan and timescale must be made in accordance with Manx Care’s Incident Policy. An incident may not meet the threshold of a Serious Incident with oversight required by the Care, Quality & Safety Team, however the Group Manager or Assistant Director of C&F may direct that a Care Group level investigation take place.

Where an incident meets the criteria of a Serious Incident (as defined in the Policy and Procedure for Incident Reporting, Investigation and Learning) a Rapid Review Process must also be followed. Serious incidents in health and social care are where the potential for learning is so great, or the consequences to service users, families, staff or organisations are so significant, they warrant using additional resources to mount a comprehensive response.

Where an incident has led to harm, Social Care professionals already have a duty to be open and honest with service users when things go wrong. This duty is now enshrined in the Manx Care (Duty of Candour Procedure) Regulations 2021and requires Manx Care to:

• Review incidents and establish whether a Duty of Candour applies
• Acknowledge, apologise and explain when things go wrong;
• Conducting a thorough investigation into any incident and reassurance that lessons have been learned;
• Providing support for those involved.

The Care, Quality and Safety Team can provide support and assistance with all aspects of the Duty of Candour process.

All notifiable incidents, inquiry and outcomes will be recorded on the carers file and on the child’s file as relevant and appropriate. Records in an anonymised form will be retained in the Datix system, overseen by Care, Quality & Safety.

If the incident is a Standard of Care Concern, please follow the Standards of Care Policy.

If the incident occurs out of hours, the Family Placement on call social worker must contact the OOH duty social worker to update them and discuss if the OOH duty manager or OOH duty senior manager need to be informed. A decision will be made regarding who will notify those with parental responsibility and when. All such notifications will occur within 24 hours of the incident.

Appendix 1: Registration and Notification Form

Appendix 2: Statutory Notification of Events (follow up) Form

Appendix 3: Process Map

Appendix 4: Manx Care Reporting and Investigation Process Flowchart