Audit template
Learning Lessons
Pulls themes from incidents, complaints and audits into organisational learning. This template runs quarterly in MyCareCompliance and carries 8 mapped checks across 4 CQC quality statements.
Last reviewed: September 2026. This guidance reflects CQC information available at the date above — always refer to cqc.org.uk for current regulatory requirements.
What the audit covers
Every question in the Learning Lessons is mapped to a CQC quality statement and the underlying regulation, so a failed check tells you exactly which part of the single assessment framework is at risk. This is an optional template you can switch on when it applies to your service.
- Runs quarterly — optional template
- Part of the Safety & governance audit category
- Maps to 2 regulations: Regulation 12 — Safe care and treatment, Regulation 17 — Good governance
- Failed checks become tracked improvement actions with an owner, due date and evidence
The 8 checks
Involving people to manage risks
Safe — 1 check- Regulation 12 — Safe care and treatmentLearning Lessons
Are care plans and risk assessments promptly updated following an incident to prevent recurrence?
What we look for: Cross-reference 3 incident reports with the corresponding person's care plan and risk assessment. Good practice shows immediate updates to care instructions (e.g., requiring two carers instead of one for mobility). Fail if the risk assessment remains unchanged despite a clear change in risk level.
Evidence: Updated risk assessments, care plan review notes, daily logs showing new instructions
Learning culture
Safe — 3 checks- Regulation 12 — Safe care and treatmentLearning Lessons
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
- Regulation 12 — Safe care and treatmentLearning Lessons
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
- Regulation 12 — Safe care and treatmentLearning Lessons
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
Governance, management and sustainability
Well-led — 2 checks- Regulation 17 — Good governanceLearning Lessons
Does the provider conduct quarterly thematic or trend analysis on incidents, accidents, complaints, and safeguarding alerts?
What we look for: Check the most recent quarterly governance report for data analysis (e.g., falls at specific times, recurrent missed visits). Good looks like data being actively grouped by theme, location, or staff member to spot patterns. Fail if data is collected but not analysed for trends.
Evidence: Quarterly quality reports, clinical governance minutes, data dashboards, trend analysis charts
- Regulation 17 — Good governanceLearning Lessons
Is there a robust system for tracking action plans generated from lessons learned through to completion?
What we look for: Review the continuous improvement or action tracker. Ensure every lesson learned has specific actions, assigned owners, and target dates. Fail if actions are left open indefinitely, or if there is no check to ensure the implemented action was actually effective.
Evidence: Continuous Improvement Plan, action trackers, meeting minutes showing action closures
Learning, improvement and innovation
Well-led — 2 checks- Regulation 17 — Good governanceLearning Lessons
Are lessons learned from internal incidents and complaints effectively communicated to all care staff?
What we look for: Review the communication channels used over the last 3 months to share learning. Look for clear, actionable messages sent to all staff (e.g., changes in manual handling protocols). Fail if there is no mechanism to share learning with remote workers who do not attend the office.
Evidence: Team meeting minutes, staff newsletters, memo sign-off sheets, spot check records
- Regulation 17 — Good governanceLearning Lessons
Does the service learn from external sources, such as Safeguarding Adult Reviews (SARs), CQC reports, and local authority alerts?
What we look for: Look for evidence that the Registered Manager reviews external best practice, coroner's reports, or regional safeguarding themes. Good looks like proactive discussion of external events and applying the learning locally. Fail if the service is entirely inward-looking with no external benchmarking.
Evidence: Management meeting minutes, updated policies based on external guidance, provider bulletins
See it running for your service
Book a free demonstration and we will run the Learning Lessons against scenarios from a service like yours, or start your 7-day trial and try it yourself.
See it with your own service
Book a free demonstration and we will walk through the platform using scenarios from a service like yours.