Shared Lives – Incident/Accident Report – SL56 No:

PART A – to be completed and sent to sharedlives@kent.gov.uk within 24 hours of incident/accident by (or on behalf of) each person affected by an accident, occupational disease, violence (actual or threat) Please tick all appropriate boxes, leave blank boxes that don’t apply, use a continuation sheet if necessary.

Person Injured/Affected
Name:
Address:

Incident/Accident Details
Date:
Time:
Location:

Accident Type (please tick one box only)
Accidents	Allegations of abuse	All other incidents
Physical injury	☐	Physical abuse	☐	Challenging behaviour Injury of	☐
Property	☐	Sexual abuse	☐	Challenging behaviour Self-injury	☐
Injury to carer or other person	☐	Financial abuse	☐	Challenging behaviour Destruction of property	☐
Self-injury to service user	☐	Psychological abuse	☐	Incident where police are called/ involved	☐
Medication error	☐	Medication error	☐	Missing person	☐
Incident where police are called / involved	☐	Neglect / omission	☐	Death of a service user	☐
Other accident	☐	Other abuse	☐	Other incident	☐
About the Incident/Accident: What happened? (who was doing what at the time of the accident). Please use additional page provided at the end of this form if required.

Describe any injury i.e., left arm, right leg etc.

Details action taken and/or of first aid or treatment given:

Signature of Carer:
Date:
Address:
If signing on behalf of the affected person please state Name & Position:

PART B – To be Completed by the Shared Lives Work or Manager

What action has been/could be taken to prevent a re-occurrence?

Recommended action to be taken?

Incidents Reportable to CQC:
Does the Adult receive personal care? (If yes, send notification to CQC if it fits under one of the current regulations)	☐ Yes	☐ No

Shared Lives Worker /	Shared Lives Manager completing this form:
Name (Print):
Signature:
Job Title:
Date:
Office Address:	Kroner House, Eurogate Business Park, Ashford, Kent, TN24 8XU
Tel No:	03000 412400

About the Incident/Accident Continuation Sheet: