Building a learning culture and sharing lessons learned

Who it applies to

All adult social care services, especially managers responsible for incidents, complaints and safeguarding.

What a learning culture looks like

• Staff report incidents and near misses without fear of blame
• Reviews look for causes in systems and processes, not just individuals
• People and families are told what happened and what has changed
• Lessons are shared in handovers, team meetings and supervision
• Themes across incidents, complaints and audits are reviewed regularly

Closing the loop

• Turn each lesson into a specific action with an owner
• Check later that the change has stuck, for example through an audit
• Record how the lesson was shared and who received it

Internal audit questions

1. 1.Are near misses being reported, or only incidents that caused harm?
2. 2.Can staff describe a recent change made after an incident?
3. 3.Are incident themes reviewed at governance meetings?
4. 4.Is duty of candour applied and recorded where required?

How MyCareCompliance can help

MyCareCompliance's incident register, action plans and governance reports help you log incidents, assign learning actions and show trends over time, giving inspectors clear evidence of a learning culture.

Official sources

• CQC: quality statements
• Regulation 17 — Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (legislation.gov.uk)
• CQC guidance on Regulation 20
• NHS England: Patient Safety Incident Response Framework