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Care Safety Report (CSR)

This is a no-blame reporting system for concerns, incidents, or near misses. If there is immediate risk, ensure the person in charge has been informed in addition to submitting this form. For more info, visit www.careflare.co.uk

Reporting Preference

Choose whether you would like this report to be anonymous
Reporting Preference

REPORTER DETAILS

Department

Select your department

Employment Type

Shift Type


EVENT DATE & TIME

Event Date

Event Time


EVENT DETAILS

Category

Location

Select where the event occurred

Description of Event

Immediate Action Taken

Describe any actions taken to make the situation safe or escalate the concern

Contributing Factors

Select any factors you believe may have contributed. This supports learning and is not about blame.

Resident Name

Room Number

Suggestions

What could help prevent this happening again?

IMPACT & RISK

Was this a near miss event?

A near miss is something that could have caused harm but was caught before it happened
Was this a near miss event?

Was anyone harmed as a result of this event?

Was anyone harmed as a result of this event?

Did anyone require medical attention?

Did anyone require medical attention?

Is there an ongoing or immediate risk if nothing changes?

Is there an ongoing or immediate risk if nothing changes?