The examples below provide insight into how other Good or Outstanding rated services are succeeding in this area of inspection.
Use the filter to choose different types of examples or select based on related prompt.
Learning from falls
In this two-minute audio clip from the Care Exchange podcast, Ben Miller talks about how following an increase in falls, he convened a task force to create a falls prevention project.
You can listen to the full podcast here. Access our whole Care Exchange series here.
Read more about this service here.
Care provider: Castleford House
Date published: December 2022
Using Lesson-learned meetings to share national guidance
To disseminate information amongst staff, this service shared learning from incidents through emails and ‘lessons-learned’ meetings. ‘Lessons-learned’ meetings happen monthly, and urgently after any serious incidents. Throughout the pandemic, these meetings have been held online. To supplement these ‘lessons-learned’ meetings, the service also share relevant information from NICE, CQC and the Adult Social Care Ombudsman, collated by registered managers.
See also: Social care guidance at NICE
Care provider: Anonymous
Date published: January 2022
Learning from residents to improve nutrition and hydration
We’re constantly looking at ways to improve and learning from mistakes, suggestions or near misses.
Our residents wanted to review our nutrition and hydration at the home, so we formed a ‘residents food committee’ with several residents, as well as the head chef, manager and other key staff.
This is very helpful, since we can ensure the residents are getting what they want, when they want it, and has developed an even more open approach to suggestions and feedback about food and nutrition within the home.
We also recently had a resident who was admitted to hospital and there were some signs of dehydration. We immediately put in place supervision and training for staff to undertake training around maintaining hydration to ensure this risk could be avoided in the future.
Read more about this service here.
Care provider: Valerie Manor
Date published: November 2021
Outstanding ways to learn when things go wrong
There was an open culture in which all safety concerns raised were used as a source of learning and improvement.
The incident reporting process had been improved to enable self-reporting by care workers. Staff were open and transparent, and reported any incidents and near misses either directly through the intranet or by raising an incident case through the 'carer services team'. All reported incidents were monitored with strict timescales for them to be reviewed, triaged and assigned a risk rating.
There was excellent management oversight at all levels of the organisation for all reported incidents. A daily report of all the cases that had been opened was sent to the care managers, regional managers, head of operations and the registered manager, which gave them an opportunity to review all the cases.
The quality assurance team monitored any incidents that had breached their resolution targets every month with regards to any investigation and an action plan. Incidents and adverse events were reported to the board every month.
There was a serious incident framework for the management of complex, high-risk incidents. These were discussed in a multi-disciplinary team meeting and supplemented by very detailed investigation reports. Regional managers reported on these every month.
Read more about this service here.
Care provider: The Good Care Group
Date published: April 2019
Working groups established to address accidents and incidents
All staff were encouraged to participate in learning to improve safety as much as possible. Accidents, incidents and near misses were discussed at team meetings and staff were central to determining ideas and solutions.
Staff formed working groups where they needed to explore the best way to approach a situation. This way of communicating was effective as it was valued by the whole staff team.
Read more about this service here.
Care provider: No Place Like Home
Date published: April 2019
Learning logs
The staff team also reflected upon everyday activities using 'learning logs' in which they questioned if and why they did or didn’t work, and how they could be improved upon for that person.
For example, one person was being supported to become more independent when swimming. Staff were taking steps back to allow the person more space and freedom whilst swimming. Then staff completed a learning log detailing what worked and what could be improved to ensure consistent support. Staff reported: "There’s an element of risk, but this is managed and calculated and the benefits to the individual who’s gaining the independence outweigh the risk."
Read more about the service here.
Care provider: SENSE - 89 Hastings Avenue
Date published: April 2019
Minimising the risk of reoccurrence
In one service, a recent incident resulted in a wrong piece of equipment accidently being used. Immediate action was taken to ensure appropriate treatment for the person involved. Procedures and protocols were then reviewed and strengthened to minimise the risk of reoccurrence. The staff member and all other staff were given training on the new system put in place. A reflective practice session was held on the incident so all nursing staff could contribute to the improvements.
Care provider: Anonymous
Date published: April 2018
Taking ownership
Following each incident report, a member of the management team had reviewed each report, made notes and signed off each one before filing them. This process was complemented by the registered manager, who made additional recommendations about how to prevent reoccurrence.
Care provider: Anonymous
Date published: April 2018
A campaign to raise awareness of medication errors
Despite effective management, training, processes and procedures, human error can occur. One provider helped reduce this through a campaign which communicated the importance of medication errors and accidents on the people needing care and support, the staff member responsible and the wider service.The hard-hitting campaign helped staff recognise the impact and take extra care when managing and administrating medications. The service also introduced formal reflection on any accident and errors as part of staff supervisions.
Care provider: Anonymous
Date published: April 2018
Involving our people in reviewing accident and incident records
We keep accident and incident records. These include when people become angry or upset, and detail events that lead up to the incident so that staff can reflect on any triggers and how they could be avoided in the future.
People using the service were included in this reflection so they could voice opinions about what had happened. Risk assessments and care plans were reviewed monthly and information from the incident analysis was added to make sure they were up-to-date, live documents and fully focused on the individual.
Care provider: Anonymous
Date published: April 2018
Alleviating concerns in an open and transparent way
Following an incident or accident, both the provider and registered manager explained to people what they were going to do to prevent reoccurrences of issues and apologised to people when things had gone wrong
Care provider: Anonymous
Date published: April 2018
Promoting an open culture
We promote an open culture based on information sharing. We provide support when things go wrong to ensure people learn and grow from these experiences, while still having the confidence to be positive risk takers. We believe that, used constructively, these experiences build positive change and strengthen our teams and organisation. Being open and working collaboratively with others, inside and outside of the organisation, has supported us to build an excellent reputation within the community.
Care provider: Belong
Date published: April 2018
Highlighting increased risks
The service introduced a 'safety cross' system (more commonly used in the NHS) alongside their accident/incident reporting, to help staff identify people at increased risk. The 'safety cross' calendar provided a visual prompt which highlighted when a person fell or was unwell. It helped staff spot trends earlier, so they could take proactive action and identify people whose risk had increased.
Care provider: Anonymous
Date published: April 2018