Incident Management Policy

Introduction

Purpose

The purpose of this Incident Management Policy is to ensure that each participant within Disability and Mental Health Care Pty Ltd is safeguarded by our comprehensive incident management system. This system ensures that incidents are acknowledged, responded to, well-managed, and learned from, in compliance with the NDIS Practice Standards and the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018.

NDIS Indicators (Objectives)

Incident Management

Outcome: Each participant is safeguarded by the provider's incident management system, ensuring that incidents are acknowledged, responded to, well-managed and learned from. To achieve this outcome, the following indicators should be demonstrated:

• An incident management system is maintained that is relevant and proportionate to the scope and complexity of supports delivered and the size and scale of the organisation. The system complies with the requirements under the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018.
• Each participant is provided with information on incident management, including how incidents involving the participant have been managed.
• Demonstrated continuous improvement in incident management by regular review of incident management policies and procedures, review of the causes, handling and outcomes of incidents, seeking of participant and worker views, and incorporation of feedback throughout the provider's organisation.
• All workers are aware of, trained in, and comply with the required procedures in relation to incident management.

Scope

This Policy is applicable to all Workers affiliated with Disability and Mental Health Care Pty Ltd. It is the responsibility of every individual, regardless of their employment status, to fully comprehend and comply with the commitments outlined in this policy. All Workers must acknowledge that they have read, understood and will comply with the contents of this Policy.

Policy Statement

At Disability and Mental Health Care Pty Ltd, we prioritise participant safety and welfare through our robust Incident Management Policy. Aligned with the NDIS Practice Standards and the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018, we strive to ensure a swift response to incidents, their efficient management, and the assimilation of insights to prevent future occurrences. This policy applies to all Workers associated with Disability and Mental Health Care Pty Ltd, who are expected to understand and adhere to the policy's commitments.

Our strategic objectives focus on fostering a culture of open feedback and effective incident management. We aim to equip each participant with vital information about our incident management process, including responses to incidents involving them. Embracing a continuous improvement mindset, we regularly review and refine our policies, analyse incident causes and outcomes, and integrate participant and worker feedback across our organisation. Training and compliance with our incident management procedures are fundamental expectations for all our workers.

Relevant legislation

All relevant legislation to this Policy is outlined in the Legislation Register.

Related documents

• Incident Report Form
• Incident Management Register
• Feedback, Complaints and Incident Considerations

Responsibilities and Roles

Supriya Thapa is responsible for the development and review of this policy. It is expected that Supriya Thapa ensures this Policy remains compliant with all applicable laws, regulations and standards.

Key Management Personnel play a vital role in ensuring the effective implementation of this Policy throughout Disability and Mental Health Care Pty Ltd. It is the responsibility of all Key Management Personnel to not only assist Workers in understanding and complying with this policy but also to comply with it themselves. By leading by example, they demonstrate the importance of adherence to the policy and foster a culture of compliance within the organisation.

Workers are responsible for understanding the contents of this policy and complying with all procedures applicable to them.

Definitions

Disability and Mental Health Care Pty Ltd means Disability and Mental Health Care Pty Ltd ABN 19658578575.

Key Management Personnel means Supriya Thapa and other key management personnel involved in Disability and Mental Health Care Pty Ltd from time to time.

Director means Supriya Thapa.

Worker means a permanent, fixed term or casual member of staff, a contractor or volunteer employed or otherwise engaged by Disability and Mental Health Care Pty Ltd and includes the Director.

An incident is defined as an act, omission, event, or circumstance. It may mean any of the following:

• Acts, omissions, events, or circumstances that occur in connection with providing NDIS supports or services to a person with disability and have, or could have, caused harm to the person with disability.
• Acts by a person with disability that occur in connection with providing NDIS supports or services to the person with disability and which have caused serious harm, or a risk of serious harm, to another person.
• Reportable incidents that have or are alleged to have occurred in connection with providing NDIS supports or services to a person with disability.

Reportable Incidents means, in connection with the supports and services provided by Disability and Mental Health Care Pty Ltd:

• the death of a person with disability; or
• serious injury of a person with disability; or
• abuse or neglect of a person with disability; or
• unlawful sexual or physical contact with, or assault of, a person with disability; or
• sexual misconduct committed against, or in the presence of, a person with disability, including grooming of the person for sexual activity; or
• the use of a restrictive practice in relation to a person with disability,

provided that an act is not a Reportable Incident if:

• the act is unlawful physical contact with a person with disability and the contact with, and impact on, the person with disability is negligible;
• the use of a restrictive practice is in accordance with an authorisation (however described) of a State or Territory in relation to the person and such use is in accordance with a behaviour support plan for the person with disability; and
• the use of a restrictive practice is in accordance with a behaviour support plan for the person with disability and the State or Territory in which the restrictive practice is used does not have an authorisation process in relation to the use of the restrictive practice,

and includes Reportable Incidents that are alleged to have occurred.

Procedures

Incident Identification and Reporting

All workers and Participants are to be reassured that there will be no negative consequences or adverse actions taken against anyone reporting or alleging that an incident has occurred.

Upon identifying or becoming aware of an incident, all Workers must report it to the Incident Manager or another Key Personnel.

In case of severe incidents that necessitate contacting emergency services to safeguard the health, safety, and wellbeing of persons with disabilities, workers, or other individuals affected by the incident, workers must first notify emergency services.

After reporting to the Incident Manager, and if deemed appropriate after consulting with the Participant first, the Incident Manager will notify the Participant's families, guardians, and advocates.

The Incident Manager has the responsibility to complete an Incident Report Form as soon as practicable after the incident, preferably within 24 hours of the incident's occurrence or when the Worker became aware of it.

For reportable incidents, the Incident Manager is responsible for notifying the NDIS Commissioner as per the NDIS guidelines listed in Appendix 1.

All reportable incidents, including the use of a restrictive practice causing serious injury, must be notified to the NDIS Commission within 24 hours of becoming aware of the incident.

Any unauthorised use of restrictive practices not causing serious injury must be notified within 5 days.

The notification must include the following information to the NDIS Commission:

• The name and contact details of the registered NDIS provider, the person making the notification and the persons involved in the reportable incident, including the person with disability affected by the reportable incident, and any subject or subjects of an allegation.
• A description of the reportable incident, including (if known) the time, date and place the incident occurred.
• A description of the impact on, or harm caused to, the person with disability (where the reportable incident is a death, this information does not need to be provided).
• The immediate actions taken in response to the reportable incident, including any actions relating to the health, safety and wellbeing of the person with disability affected by the incident, including medical treatment provided, and whether the incident has been reported to the police or any other body.

If the specific information required in the form is not available within 24 hours of becoming aware that a reportable incident has occurred, the remaining information may be provided to the NDIS Commission within five business days.

Furthermore the NDIS Commission must be notified within five business days of:

• The names and contact details of any witnesses to the reportable incident (including workers, people with disability or third parties).
• Any further actions proposed to be taken in response to the reportable incident.

The reportable incident 5-day notification form requires the registered NDIS provider to provide information from the immediate notification form as well as the following additional information:

• The name and contact details of the support person for the impacted person with disability.
• The name and contact details of the individual or person with disability who is the subject of the allegation.
• A description of the impact on, or harm caused to, the person with disability.
• The name and contact details of any witnesses to the reportable incident.
• A description of support provided, and further action being considered for the person with disability impacted by the incident and for the subject of the allegation.
• A description of the risk processes being undertaken by the registered NDIS provider.
• If applicable, circumstances surrounding the death of a person with disability.
• If applicable, details surrounding the use of an unauthorised restrictive practice in relation to a person with disability.

The Incident Manager is also responsible for informing other necessary state, territory, or federal authorities, or any other persons as per the applicable law.

Incident Recording

The Incident Manager or Key Personnel who was informed about the incident must record it in the Incident Register. This should be done promptly, no later than 24 hours after the incident was reported.

The Incident Register is a confidential document that tracks and documents all incidents. It must include:

• Date, time, and place of the incident or when it was first identified.
• Details of the persons involved in the incident.
• Whether the Incident Form has been completed.
• Witnesses to the incident.
• A description of the incident.
• Whether it is a Reportable Incident (or alleged Reportable Incident).
• What agencies the incident has been reported to.
• Details of the assessment undertaken.
• Actions taken in response to the incident.
• Consultations conducted with persons with disabilities.
• Details and outcomes of any investigation conducted.
• Reports or findings provided to participants affected by the incident.
• The affected person's response.
• Date of incident resolution and date of implementation of preventative measures.
• Incident Manager details.

Incident records will be stored securely and retained in accordance with applicable legislative requirements. An incident recorded must be kept for 7 years from the day the record is made. Access to the Incident Register will be restricted to authorised personnel only.

Incident Investigation

The Incident Manager is the individual who is tasked with the responsibility of proficiently handling and overseeing incidents.

Following the report and recording of an incident, the Incident Manager will conduct a thorough investigation, the extent and nature of which are determined by the Incident Manager in accordance with applicable legislation. In the case of a Reportable Incident, an internal investigation is mandatory.

Incidents involving potential criminal allegations are reported to law enforcement authorities, who will receive full support in their investigations.

The Incident Manager will gather all necessary information, interview witnesses if required, and document the facts surrounding the incident.

Records of incident investigations, including correspondence such as phone conversations, emails, documents, and where possible, records of face-to-face interviews, are maintained and kept confidential.

Incident Response

Appropriate actions are determined based on the nature and severity of the incident. Actions can range from immediate steps to ensure safety, arranging for support and medical intervention, or other responses as required.

In response to any incident, a comprehensive approach will be employed based on the nature and severity of the incident. Initial actions can involve immediate measures to ensure the safety of all involved, providing necessary support to those affected, coordinating medical intervention as needed, and initiating any other appropriate responses to manage the situation effectively.

The Incident Manager shall conduct a thorough assessment to determine the appropriate course of remedial action, weighing the measures to the severity of the incident. These actions could include, but are not limited to:

• In circumstances where Disability and Mental Health Care Pty Ltd is found to be at fault, a sincere apology will be extended to all affected parties.
• If the incident involves misconduct or a breach of policies by a Worker, disciplinary actions may be undertaken in line with our internal policies and legal obligations, ranging from counselling and training to suspension or termination.
• Depending on the specific circumstances of the incident, other remedial actions. These could include revising existing policies, conducting further Worker training, or implementing new safety measures to prevent similar incidents in the future.

During this assessment, the Incident Manager will consult with the Participant(s) involved, their families and advocates at regular intervals regarding the management, resolution and decisions related to the incident. This consultation process involves obtaining the Participant's viewpoints on a range of matters, including:

• Assessing whether the incident could have been prevented.
• Evaluating how well the incident was managed and resolved.
• Discussing what, if any, remedial actions need to be taken to prevent similar incidents in the future or to minimise their impact.
• Deciding whether other persons or bodies need to be informed of the incident.

After considering the Participant's viewpoints on these matters, the Incident Manager will make a final decision.

Participant Support During Incident Management

Throughout all stages of incident reporting, the safety and wellbeing of all individuals involved is the foremost priority for Disability and Mental Health Care Pty Ltd. In order to ensure this, we provide comprehensive support to our Participants during every step of the incident management process, from immediate response to final assessment. The support mechanisms to achieve this include:

• Ensuring the Participant that reported the incident feels comforted and reassured, minimising any potential distress.
• Maintaining clear and ongoing communication with the Participant, keeping them informed about the progress and outcomes of any investigations related to the incident and ensuring their concerns are promptly addressed and resolved.
• Assisting Participants in accessing necessary trauma and counselling services to facilitate emotional recovery and resilience-building post-incident.
• If necessary and feasible, making changes to regular services and supports to better accommodate the Participant's needs and enhance their comfort and wellbeing in the aftermath of the incident.

Incident Review

If any worker becomes aware of significant new information in relation to an incident after the investigation has been concluded, they must immediately provide that information to the Incident Manager.

The Incident Manager will then review relevant aspects of the incident management process based on the significance of the new information received, ensuring the continued transparency, accountability, and integrity of our incident management process.

If this new information is significant and relates to a change in the kind of Reportable Incident previously notified to the NDIS Commission, or constitutes a further Reportable Incident, the Incident Manager must immediately notify the NDIS Commission of this significant new information. This notification should occur as soon as is reasonably practicable after becoming aware of the information.

After an incident, a review will also be conducted to identify systemic issues and opportunities for improvement. Recommendations for improvement will be made and implemented to prevent a recurrence of similar incidents.

Training

All Workers will receive induction training on the Incident Management Policy and Procedures and a refresher course whenever there are significant updates or changes. As a part of their training, all our workers are taught to understand:

• The functionality and application of the Incident Management Procedures.
• The definition and significance of a Reportable Incident.
• The correct procedures for reporting all incidents to management and, if required, to an external body.

In order to effectively manage serious incidents, especially those potentially involving a criminal element and requiring procedural fairness, the Incident Manager may undergo additional specialised training.

Regular Review of Incident Register

The Incident Register will be reviewed regularly (at least annually) by the management team to identify trends and systemic issues, and to ascertain opportunities for improvement in our service delivery and risk management procedures. This review forms part of our commitment to continuous improvement and our proactive approach towards incident management.

Confidentiality and Disclosure

Disability and Mental Health Care Pty Ltd is committed to maintaining the confidentiality of all incident-related information.

Disclosure will only occur if legally mandated, or if deemed necessary and appropriate under specific circumstances to balance privacy, procedural fairness, comprehensive incident investigation, and legal compliance. Appropriate disclosure scenarios may include sharing information with relevant Workers, legal advisors, or regulatory bodies like the NDIS Commission.

When reporting an incident to the NDIS Commission, Disability and Mental Health Care Pty Ltd is not required to obtain or notify the NDIS Commission of certain information if obtaining that information would, or could reasonably be expected to, prejudice a criminal investigation into the reportable incident, or cause harm to a person with disability.

Policy review and updates

This Policy is to be amended and updated according to the requirements to comply with the applicable laws and regulations.

Appendix 1: notifying the NDIS Commission of a reportable incident

This appendix is an extract of the NDIS Quality and Safeguards Commission's guidance. It outlines the reporting requirements, including timeframes and required forms. Registered NDIS providers use the NDIS Commission Portal's "My Reportable Incidents" page to notify and manage all reportable incidents.

Step 1: notify the NDIS Commission. The Immediate Notification Form must be submitted via the NDIS Commission Portal within 24 hours of key personnel becoming aware of a reportable incident or allegation. The form covers details of the reportable incident, actions taken in response, and the individuals involved. An exception is the use of a restrictive practice that is unauthorised or not in accordance with a behaviour support plan: the provider must notify the NDIS Commission within five business days of being made aware of the incident, unless it has resulted in harm to a person with disability, in which case it must be reported within 24 hours. The authorised "Approver" reviews and is responsible for submission; an authorised "Notifier" can prepare a draft notification for the Approver to review and submit.

Step 2: submit a 5 Day Form. The 5 Day Form must be submitted via the portal within five business days of key personnel becoming aware of a reportable incident. It provides additional information and the actions taken by the provider. It is also used for incidents involving the unauthorised use of a restrictive practice, other than those resulting in immediate harm to a person with disability.

Step 3: submit a final report, if required. The NDIS Commission will notify the provider by email if a final report is required and the date it is due. In all cases, providers must assess: the impact on the NDIS participant; whether the incident could have been prevented; how the incident was managed and resolved; what, if any, changes will prevent further similar events occurring; and whether other persons or bodies need to be notified.

In certain instances, the NDIS Commission may require detailed information about a reportable incident within 60 business days (or a longer period it specifies) following an initial notification, submitted in writing: the specifics of any internal or external investigation or assessment (the identity and role of the investigator, the timeframe, and any conclusions drawn); detailed information on any corrective measures or other actions implemented; a full report of the investigation or assessment; confirmation that the people with disability affected (or their representatives) have been informed about the progress, findings and subsequent actions; and any other information the Commissioner requests. Where appropriate, the NDIS Commission may require a provider to take remedial measures, work with the provider to implement them and monitor progress; these may include additional worker training and development, improved services to support NDIS participants, and updating policies and procedures.

If you are unable to log in to make a report, go to https://www.ndiscommission.gov.au/providers/complaints-and-incidents/notify-us-about-reportable-incident and follow the outlined steps.

Approval Authority	Supriya Thapa
Version	1
Approval Date	August 2025
Review Date	August 2027