Complex Care Event Reporting Form
If the service user you would like to report on is not listed below, please contact the Complex Care Team at ComplexCareTeam@creativesupport.co.uk to make a referral.
Service user name *
If the Service User's name is not in this list, please complete the standard incident form instead
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Site *
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When did the event take place? *
- During morning shift
- During day time handover from early to afternoon/late staff
- During afternoon/late shift
- During handover from late to night/sleep-in shfit
- During night/sleep-in shift
- During handover from night/sleep-in to morning shift
Are you...? *
If no one else was present apart from you and the service user who is the subject of this report, please enter "0". If any other people were present, please enter a number between 1 and 5.
Did this event occur at the service user's home? *
- Yes
- No
Did the behaviour occur while in a vehicle? *
- Yes
- No
Did the behaviour occur or continue anywhere else? *
- Yes
- No
Describe the antecedent *
This is what was happening before the behaviour event started. It includes setting events and triggers. You will be asked to describe and then to categorise this antecedent.
- {name}
Antecedent categories *
How would you categorise the antecedent(s) you have just described?
- Change in routine
- Engaged in a task
- Having to wait
- Lack of stimulation / boredom
- Not having access to something they wanted
- Not having attention / being ignored
- Overstimulation (crowd / noise / temperature / lighting)
- Overwhelmed by a task or instruction
- Pain / ill / physical discomfort
- Person on their own
- Prolonged interaction
- Repetitive questioning
- Request / demand made of the person
- Requesting something
- Sensory related issues
- Tired
- Told "no"
- Transition between events / people / places
- Unfamiliarity (people / event / places)
- Wanting a favourite activity or item
- Wanting food / drink
- Decline in mental health
- Other
Select the antecedent you think most contributed *
- Change in routine
- Engaged in a task
- Having to wait
- Lack of stimulation / boredom
- Not having access to something they wanted
- Not having attention / being ignored
- Overstimulation (crowd / noise / temperature / lighting)
- Overwhelmed by a task or instruction
- Pain / ill / physical discomfort
- Person on their own
- Prolonged interaction
- Repetitive questioning
- Request / demand made of the person
- Requesting something
- Sensory related issues
- Tired
- Told "no"
- Transition between events / people / places
- Unfamiliarity (people / event / places)
- Wanting a favourite activity or item
- Wanting food / drink
- Decline in mental health
- Other
Please describe the behaviour event itself, including all relevant details and information. *
- {name}
Which categories best describe the nature of the behaviour event? *
- Person left staff support
- Damage to items/property
- Verbal aggression: staff
- Verbal aggression: family/public
- Verbal aggression: other service user
- Physical aggression: staff
- Physical aggression: family/public
- Physical aggression: other service user
- Self injurious behaviour
- Sexualised behaviour
- Smearing/urination/vomiting etc
- Other
Select the space zone that best describes your proximity during the behaviour event *
- Intimate (0-45cm)
- Personal (45cm-1.2m)
- Social (1.2-3.6m)
- Public (3.6m+)
During the behaviour event, did you administer PRN (as required) medication? *
- Yes
- No
Were any restrictive practice techniques used? *
This refers to any protective/breakaway or removal and safe holding techniques. If the use of these techniques was not involved, please select "No"
- Yes
- No
Description of consequences *
This is what happened after the behaviour event finished. It includes what the person gained or avoided as a result of their behaviour. Think about your actions as well as their actions. You will be asked to describe and then to categorise the consequence(s).
- {name}
Did any of the following happen in response to the behaviour event? *
Select any that apply
- Advised behaviour is inappropriate
- Behaviour ignored/minimal interaction
- Carried on with plans
- Change in staff
- Gains attention/reassurance
- Given medication
- Given preferred item/activity
- Given space/left alone
- Police attended
- Prevented access to something
- Provided additional information
- Redirected attention/distraction
- Removed trigger
- Repeated instruction
- Request/activity is discontinued
- Self-stimulatory behaviour
- Staff made situation safe
- Told not to do something/set boundary
- Used coping strategy
- Used humour
- Other
Select the consequence you think is most relevant as the outcome in response to the person's behaviour *
Select one option from the items you have ticked above
- Advised behaviour is inappropriate
- Behaviour ignored/minimal interaction
- Carried on with plans
- Change in staff
- Gains attention/reassurance
- Given medication
- Given preferred item/activity
- Given space/left alone
- Police attended
- Prevented access to something
- Provided additional information
- Redirected attention/distraction
- Removed trigger
- Repeated instruction
- Request/activity is discontinued
- Self-stimulatory behaviour
- Staff made situation safe
- Told not to do something/set boundary
- Used coping strategy
- Used humour
- Other
Severity *
Severity is the impact of a person's behaviour on themselves, their environment and the people around them. Please select any that apply.
- Proactive strategies effective
- Damage to property/environment
- Service user: mark to skin with no treatment
- Service user: injury sustained with first aid
- Service user: injury sustained with medical treatment
- Staff/other: mark to skin with no treatment
- Staff/other: injury sustained with first aid
- Staff/other: injury sustained with medical treatment
- Service user: any psychological impact
- Staff/other: any psychological impact
Please provide relevant detail about the impact of the person's behaviour on themselves or others. *
- {name}
Is there any other information you would like to share that is relevant to help us to understand the context of this event, or anything you feel we should reflect on?
This may be anything that could have contributed to the event; or your views on what worked or could be improved in future.
- {name}
Who did you notify? *
- Local manager
- Local on call
- Out of Hours (Head Office)
- Emergency services
- Family/carer/next of kin
- Local authority/safeguarding
- Other
Being involved in a behaviour event can be emotionally as well as physically challenging. To support staff involved in these events, Creative Support's policy is to offer the opportunity for individuals to Reflect and Review the support they need as well the event itself.
If you would like to arrange a Reflect and Review meeting with your line manager, please tick the box below. Your answer to this question will be treated confidentially, and not included in the complex care event report
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