Incident Management Procedure

1. Statement

An incident is an undesirable event that could adversely impact the well-being and safety of our clients and employees. Horizon Therapy Services aims to provide effective management of incidents in accordance with our obligations under the NDIS Act 2013, its associated rules and practice standards.

2. Purpose

These procedures provide employees with an effective, standardised system of reporting and managing incidents. It also tells management about problems so that work practices can be reviewed to reduce the likelihood of the incident happening again.

This procedure will:

  • Provide means of quickly identifying unmet needs for extra support or training
  • Provide a picture of developing patterns of incidents, which may necessitate a change in work practices in order to better safeguard our clients and employees
  • Provide a record of the incident in case later reference is needed.

3. Responsibilities

All employees are responsible for implementing this procedure. The Practice Manager is responsible for monitoring and responding to incidents and the Business Manager is responsible for ensuring that incident reports are completed and logged on the incident register. The Management Committee is responsible for reviewing incidents to identify patterns or issues that may require a review of policies and/or change in work processes and practices.

4. Procedure

When an accident occurs employees must:

  • Ensure the immediate safety of clients and other employees and render First Aid if required
  • Call 000 – if required (Police, Fire, Ambulance) – refer to Responding to Emergencies procedure
  • If the incident is a Category 1 or 2 incident, notify the Practice Manager by phone or email as soon as is practicably possible and no later than 2 hours following the incident occurring
  • If the incident is a Category 3 incident notify the Practice Manager by phone or email within 24 hours of the incident occurring
  • Immediately notify families, carers and guardians of a Category 1 or 2 incident and if a client is injured
  • Complete a Horizon Therapy Services Incident Report within 24 hours of the incident occurring and submitting it to the Practice Manager and Business Manager via email.
  • If required, notify the NDIS Commission (refer below).

5. Incident Categories

Category 3 incidents

  • Minor injury to a client and/or their carer – First Aid not required
  • Minor injury to an employee – First Aid not required
  • Verbal abuse
  • Minor property damage

Category 2 incidents

  • injuries to employees requiring First Aid
  • injuries to clients and/or carers requiring First Aid
  • Significant property damage

Category 1 incidents

  • serious injury to employees requiring medical treatment/hospitalisation
  • serious injury to clients and/or carers requiring medical treatment/hospitalisation
  • any incident involving the police, fire or ambulance services
  • events with health and safety implications, e.g. fire hazards such as the storage of chemicals or an attempted break and enter
  • events that may be of significant interest to the media.

6. Investigation and assessment of incidents

Following the incident, the Practice Manager will complete an assessment with regard to the following issues:

  • whether the incident could have been prevented
  • how well the incident was managed and resolved
  • what, if any, remedial action needs to be undertaken to prevent further similar incidents from occurring, or to minimise their impact, and
  • whether other persons or bodies need to be notified of the incident.

The Practice Manager will also consider the outcome of the assessment to determine what further action should be taken, which could include:

  • providing ongoing support to impacted people with disability and/or ensuring the ongoing wellbeing and safety of impacted people with disability
  • identifying and implementing practice improvement measures
  • notifying the NDIS Commissioner and/or other bodies or agencies, if appropriate
  • undertaking further investigations
  • identifying and taking corrective action to prevent a reoccurrence of incidents, or
  • deciding that no further action is necessary.

The Practice Manager will record the outcome of their assessment on the Horizon Therapy Services Incident Report form.

7. Process for initiating and conducting investigations

In some circumstances it may be necessary to conduct a more formal investigation to establish the cause of a particular incident, its effect and any operational issues that may have contributed to the incident occurring.

Process for conducting internal and external investigations:

  • Category 2 and most Category 3 incidents: internal investigation by the Practice Manager or delegated employee as per section 6 in this document.
  • The approach, process undertaken, findings and recommendations of the internal investigation will be documented in a way that is proportionate to the severity of the incident.
  • If police are involved, an internal investigation should not commence until the police have completed their inquiries.
  • Category 3 incidents involving assault, sexual assault and/or hospitalisation of a client: external investigation conducted by an appropriately qualified investigator. Refer to the NDIS Commission’s NDIS Procedural Fairness Guidelines during the course of conducting any investigation into an incident.

8. Support to clients

  • If a client is injured while receiving services from us, employees must ensure that they receive medical attention appropriate to the severity of the injury
  • In the event of a serious incident e.g. assault staff should offer counselling to affected clients.
  • The Practice Manager will invite clients to be involved in the management of the resolution of the incident and this will be recorded in the Practice Manager’s report: post-incident review section on the Incident Report template.

9. Notifying the NDIS Quality and Safeguard Commission

9.1 Incident notification to the NDIS Commission

Registered providers must report to the NDIS Commission serious incidents (including allegations) arising in the context of NDIS supports or services, including:

  • the death of an NDIS participant
  • serious injury of an NDIS participant
  • abuse or neglect of an NDIS participant
  • unlawful sexual or physical contact with, or assault of, an NDIS participant
  • sexual misconduct committed against, or in the presence of, an NDIS participant, including grooming of the NDIS participant for sexual activity
  • the unauthorised use of a restrictive practice in relation to an NDIS participant.

9.2 Timeframes and reports

Most reportable incidents must be notified to the NDIS Commission within 24 hours of a provider’s key personnel being made aware of it, with a more detailed report about the incident and actions taken in response to it to be provided within 5 business days.

The unauthorised use of restrictive practice must be notified to the NDIS Commission within 5 business days of a provider’s key personnel being made aware of it. If there is harm to a participant, it must be reported within 24 hours.

A final report may also be required within 60 business days of submitting the five-day report. The NDIS Commission will advise providers whether a final report is required.

In all cases, the following must be assessed:

  • the impact on the NDIS participant
  • whether the incident could have been prevented
  • how the incident was managed
  • what, if any, changes are required to prevent further similar events occurring.

The Commission must be notified using the following forms:

Reportable incident – immediate notification: Reportable Incident – Immediate Notification

Reportable incident – 5-day notification: Reportable Incident – 5-day notification form

Once a form is completed, email it directly to the NDIS Commission at:

Further guidance on responding to reportable incidents is contained in the NDIS Commission’s Reportable incidents guidance for providers document: NDIS Commission Draft Reportable Incidents Guidance for Providers

10. Minimum record keeping requirements

Under the NDIS Incident Management requirements, for each incident, registered NDIS providers must record, at a minimum, the following details:1

  • a description of the incident, including the impact on, or harm caused to, any person with disability
  • whether the incident is a reportable incident
  • if known, the time, date and place at which the incident occurred or if not known, the time, date and place at which the incident was first identified
  • the names and contact details of the persons involved in the incident and any witnesses to it
  • the actions taken in response to the incident, including action taken to support or assist a person with disability impacted by an incident
  • if an investigation is undertaken by the provider in relation to the incident —the details and outcomes of the investigation, and
  • the name, position and contact details of the person making the record of the incident.

All records must be kept for seven years from the day that the record is made.2

11. Notifiable incident reporting in the ACT

Any person conducting a business or undertaking from which the notifiable incident arises must notify Access Canberra immediately after becoming aware that it has occurred.

If the ‘notifiable incident’ arises out of more than one business or undertaking, then each must ensure that the incident has been notified to Access Canberra. In these circumstances the duty holders must, so far as is reasonably practicable, consult, cooperate and coordinate to put appropriate reporting and notification arrangements in place.

Notifiable incidents include:

  • the death of a person
  • a serious injury or illness of a person
  • a dangerous incident.

A serious injury or illness includes:

  • an injury or illness that requires immediate treatment as an in-patient in hospital (an in-patient in hospital is a person who has been admitted to hospital and requires at least one overnight stay)
  • amputation
  • serious head, eye or burn injury
  • degloving or scalping
  • spinal injury
  • loss of bodily function
  • serious laceration
  • exposure to a substance which requires medical treatment within 48 hours.

A dangerous incident means any incident in relation to a workplace that exposes a worker or any other person to a serious risk to a person’s health or safety emanating from an immediate or imminent exposure to:

  • an uncontrolled escape, spillage or leakage of a substance
  • an uncontrolled implosion, explosion or fire
  • an uncontrolled escape of gas or steam
  • an uncontrolled escape of a pressurised substance
  • electric shock
  • the fall or release from a height of any plant, substance or thin
  • the collapse, overturning, failure or malfunction of, or damage to, any plant that is required to be authorised for use in the Work Health and Safety Regulation 2011;
  • the collapse or partial collapse of a structure;
  • the collapse or failure of an excavation or of any shoring supporting an excavation;
  • the inrush of water, mud or gas in workings, in an underground excavation or tunnel;
  • the interruption of the main system of ventilation in an underground excavation or tunnel; or,
  • another event prescribed in the Work Health and Safety Regulation 2011.

For more information refer to:

12. Availability of records

Horizon Therapy Services commits to making our records available to auditors as part of our quality assurance process will and contribute to NDIS Commission and/or WorkSafe ACT investigations relating to incidents.

13. Further information

For further information on this procedure, contact Helen Shayler, General Manager at