Incidents / Accidents Audit

Are personal and environmental risk assessments immediately reviewed and updated following an incident?

What we look for: Trace an incident (e.g., a fall) through to the person's risk assessments. Verify that the falls risk assessment was updated with new mitigation measures. A fail is finding identical, unchanged risk assessments weeks after a significant incident.

Evidence: Updated risk assessments, incident follow-up checklists, date-stamped document revisions

Are all incidents and accidents recorded promptly, accurately, and with sufficient detail regarding immediate actions taken?

What we look for: Sample 5 recent incident reports. Look for clear timelines, factual descriptions, and immediate actions taken to make the person safe (e.g., calling emergency services, first aid). A fail is finding vague descriptions, missing dates/times, or lack of immediate action documented.

Evidence: Accident/incident forms, digital care logs, on-call logs, first aid records

Are robust investigations conducted for incidents to identify root causes and contributing factors?

What we look for: Review investigation files for moderate/severe incidents. Ensure the manager explores 'why' it happened rather than just 'what' happened (e.g., rushed visits, faulty equipment). A fail is simply closing the incident without exploring underlying causes.

Evidence: Investigation reports, root cause analysis (RCA) documents, witness statements, manager review notes

Are statutory notifications to CQC and safeguarding referrals made without delay where incidents meet the threshold?

What we look for: Cross-reference incident logs with CQC notification submissions and safeguarding tracker. Look for prompt reporting (usually within 24-48 hours). A fail is finding serious injuries, police involvement, or abuse allegations in daily notes without corresponding notifications.

Evidence: CQC notification records, local authority safeguarding logs, incident reports, accident book

Are people's care plans updated to reflect any changes in care delivery required to prevent recurrence?

What we look for: Review the care plan of someone who recently had an accident. Ensure the plan reflects new interventions (e.g., using a different transfer technique, removing trip hazards). A fail is care plans failing to reflect the new reality post-incident.

Evidence: Care plans, daily notes, communication books, handover records

Is the Duty of Candour applied correctly for notifiable safety incidents, including verbal and written apologies?

What we look for: Identify any 'notifiable safety incidents' (moderate harm or above). Check for evidence of a verbal apology, followed by a formal written apology and explanation of the investigation. A fail is failing to recognise a qualifying incident or missing the written apology.

Evidence: Duty of Candour log, correspondence with next of kin/service user, incident investigation files

Does management conduct routine trend analysis to identify recurring themes and take proactive preventative action?

What we look for: Examine the monthly incident overview. Look for analysis by time, location, staff member, and incident type to spot patterns (e.g., falls always happening at 8pm). A fail is merely counting the number of incidents without analyzing data for trends.

Evidence: Monthly audit reports, KPI dashboards, incident matrix, management meeting minutes

Is learning from incidents systematically shared with all staff to improve practice and prevent recurrence?

What we look for: Look for evidence that anonymised lessons from incidents are communicated to the wider team (e.g., "Lessons Learned" agenda item in staff meetings). A fail is a culture where incidents are dealt with in silos and the wider team remains unaware of new preventative measures.

Evidence: Team meeting minutes, staff newsletters, memos, supervision records, handover sheets