Learning culture

Is there clear evidence that learning from complaints is implemented and shared with the wider staff team to prevent recurrence?

What we look for: Look for the 'so what?' following a complaint. Sample 2 upheld complaints and trace the resulting action plan. Good practice involves discussing anonymised lessons at team meetings. Fail if complaints are closed with no tangible service improvement.

Evidence: Team meeting minutes, memos, updated risk assessments, revised policies, action plans

Is there documented evidence that learning and subsequent actions from notified incidents are reviewed to prevent reoccurrence?

What we look for: Trace a notified incident through to its conclusion. Good looks like discussion at team meetings, updated risk assessments, or policy reviews as a direct result of the incident. Fails if notifications are treated merely as a compliance tick-box with no subsequent learning loop.

Evidence: Governance Meeting Minutes, Quality Assurance Reports, Updated Care Plans/Risk Assessments

Are driving-related incidents, accidents, or near-misses during work hours accurately reported, investigated, and used to drive learning?

What we look for: Review the incident log for any road traffic accidents or near misses involving staff on duty. Ensure they are fully investigated to identify root causes (e.g., tight rotas causing rushing) and that learning is shared with the team. A fail is lack of reporting or zero follow-up.

Evidence: Accident/incident logs, Investigation reports, Team meeting minutes, Updates to driving risk assessments

Can staff articulate what it means to be open and transparent, and do they know how to report incidents that may trigger the Duty of Candour?

What we look for: Sample 3-5 staff members. They should understand they must immediately report errors or harm to the manager so families can be informed. Fails if staff believe they should hide mistakes or do not know the whistleblowing/incident process.

Evidence: Staff training matrix, records of staff interviews/supervisions, team meeting minutes

Is learning from incidents that trigger the Duty of Candour shared with the wider staff team to prevent recurrence?

What we look for: Check how the outcome of a DoC investigation was utilized. Staff should have been briefed (anonymously if needed) on what went wrong and what new practices to adopt. Fails if there is no evidence of shared learning following a major incident.

Evidence: Team meeting minutes, memos, newsletters, updated risk assessments, lessons learned logs

Are falls incidents accurately reported, recorded, and escalated to management and families without delay?

What we look for: Cross-reference daily notes mentioning a fall with the central incident log. Good looks like prompt reporting to the office, family, and relevant professionals. Fail if falls are mentioned in daily logs but no incident report is filed.

Evidence: Accident/incident logs, daily records, communication logs with next of kin

Are incidents, accidents, and near misses systematically analyzed for patterns and trends to prevent recurrence across the service?

What we look for: Look for evidence that management reviews incidents collectively, not just individually. Good looks like monthly trend analysis identifying risks (e.g., missed visits on specific routes). Fail if incidents are filed without wider service analysis.

Evidence: Incident reporting matrix, Monthly trend analysis reports, Post-incident reviews

Are accidents, incidents, and near-misses properly recorded, investigated, and analysed for trends to prevent recurrence?

What we look for: Review the incident log for the last quarter. Check for robust investigations, root cause analysis, and shared learning. A fail is a lack of management review, repeat incidents without intervention, or failure to submit a required RIDDOR.

Evidence: Accident/Incident log, Investigation reports, RIDDOR submissions, Team meeting minutes, Post-incident action plans

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

Is there a documented procedure for reporting, managing, and learning from infectious disease outbreaks or IPC breaches?

What we look for: Review the outbreak management plan and recent incident logs regarding infections (e.g., a flu or COVID outbreak among staff/clients). Look for evidence of lessons learned, communication with local health protection teams, and CQC notifications where required. A fail is having no contingency plan for a localized outbreak.

Evidence: Incident logs, Outbreak management plan, Meeting minutes, Notifications

Is there a robust system for logging, investigating, and reporting data breaches and near misses?

What we look for: Review the breach log. Good looks like all minor incidents (e.g., email sent to wrong person) are logged, investigated, and learning is shared. Fail: no log exists or failure to notify the ICO when required.

Evidence: Data breach log, incident reports, ICO notification records, post-incident reviews

Are all accidents, incidents, and near misses recorded accurately with immediate actions taken to ensure people's safety?

What we look for: Sample 5 recent incident reports across different people receiving care. Good practice shows immediate risk mitigation, accurate time-stamping, and clear factual descriptions. Fail if records are missing, illegible, or show a delay in immediate safety actions.

Evidence: Accident/incident logs, electronic care management system alerts, safeguarding referrals

Is there evidence of comprehensive root cause analysis (RCA) or investigation for moderate to severe incidents?

What we look for: Review investigations for the 3 most significant recent incidents. Ensure the manager has explored 'why' the incident happened rather than just 'what' happened, avoiding purely blaming staff. Fail if investigations are superficial or do not identify contributing systemic factors.

Evidence: Completed RCA forms, manager investigation reports, witness statements, post-incident reviews

Can staff demonstrate their understanding of recent lessons learned and how it has changed their practice?

What we look for: Interview 3-5 care workers and ask them about a recent change in practice resulting from an incident or complaint. Good looks like staff confidently explaining the change and why it is important. Fail if staff are unaware of any recent learnings or changes to service delivery.

Evidence: Staff interview notes, supervision records, field observation notes

Is there a robust system for analyzing incidents, accidents, and near misses to identify trends and implement lessons learned?

What we look for: Review the incident tracker for the last quarter. Good looks like evidence of root cause analysis and proactive changes to care delivery. Fail if incidents are logged but not analyzed for trends, or staff are unaware of lessons learned.

Evidence: Incident logs, quarterly trend analysis reports, team meeting minutes showing shared learning, updated risk assessments

Are medication errors and near misses consistently reported, investigated, and analysed to identify trends and prevent recurrence?

What we look for: Examine the incident log for medication errors. Good practice shows thorough investigation, retraining/supervision for the staff involved, and sharing lessons learned with the wider team. A fail is seeing repeat errors by the same staff member with no documented intervention.

Evidence: Incident logs, medication error reports, investigation records, team meeting minutes

When medication errors occur, is there documented evidence of immediate competency reassessment or targeted retraining?

What we look for: Cross-reference recent medication incidents with the staff files of those involved. There should be evidence of formal reflection, supervision, or a full field reassessment before they resume full medication duties.

Evidence: Medication error logs, Incident reports, Reflective practice forms, Reassessment records

Is a thorough Root Cause Analysis (RCA) completed for every missed visit to determine exactly why the failure occurred?

What we look for: Review the investigation for recent missed visits. Ensure it digs into the 'why' (e.g., rostering error, staff no-show, car breakdown, ECM failure). A fail is superficial investigations that blame 'human error' without fixing the system.

Evidence: Investigation reports, Root Cause Analysis forms, Staff interview notes, ECM audit logs

Are moving and handling incidents, accidents, and near misses reported and learned from?

What we look for: Sample incident records involving falls, skin tears during transfers, or equipment failure. Good looks like immediate action taken, root cause analysis, and lessons shared with the team (e.g., via memos/meetings). Fail if incidents are recorded but no preventative action or care plan update occurs.

Evidence: Accident/incident logs, near miss forms, safeguarding referrals, team meeting minutes.

Is there evidence that actions arising from serious incidents or safeguarding alerts have been fully implemented in frontline practice?

What we look for: Sample 3 recent incidents. Cross-reference the resulting actions (e.g., updating a mobility risk assessment) with the actual care record. Good looks like immediate, tangible updates to records. Fails if actions are marked 'done' on the tracker but care plans remain unchanged.

Evidence: Post-incident action plans, updated risk assessments, updated care plans, spot check records

Are risk assessments immediately updated following an incident, accident, or change in the person's condition?

What we look for: Select 3 service users who recently had an incident (e.g., a fall). Check if their falls risk assessment and care plan were updated subsequent to the incident. A fail is a recurrent issue with no reassessment of risk.

Evidence: Accident/incident logs, updated risk assessments, hospital discharge summaries

Are lessons learned from safeguarding incidents effectively analyzed and shared with the wider staff team to prevent recurrence?

What we look for: Look for evidence of 'closing the loop' after a safeguarding incident is resolved. Good looks like anonymized case studies discussed in team meetings and corresponding updates to risk assessments. A fail is incidents being closed with no documented reflection or shared learning.

Evidence: Root cause analysis reports, Team meeting minutes, Memos/Newsletters, Action plans

Is the Duty of Candour consistently applied, ensuring service users are informed, supported, and apologised to following safety incidents?

What we look for: Check incident logs for notifiable safety incidents to ensure the Duty of Candour was triggered. Good practice shows a prompt verbal apology followed by a written letter explaining what happened and lessons learned. A fail is the absence of an apology or failure to inform the service user/family of a significant incident.

Evidence: Accident/Incident logs, Duty of Candour letters, Care notes, Manager's communication log