GO Online: Inspection toolkit

Learning culture

Even with the most robust risk assessments and best staff, accidents and incidents do occur in adult social care services. The CQC expects all regulated services to have a proactive and positive culture committed to identifying, investigating, and learning from each safety incident.

The following film provides a summary of this area of inspection. It can help you and your teams learn about what will be inspected and what is important to demonstrate to deliver good or outstanding care.

Learning culture

• We empower and encourage people to raise concerns to minimise future accidents and incidents.
• We can evidence how we listen and respond to safety concerns.
• We have clear records of all accidents and incidents at our service.
• We focus on identifying the root cause of accidents and incidents and plan to avoid or minimise reoccurrence.
• Where people are at risk, we make immediate adjustments and improvements to ensure our people remain as safe as possible.
• We ensure our managers and leaders are alerted to all accidents and incidents.
• Our managers and leaders take responsibility for ensuring accidents and incidents are fully and effectively investigated.
• We review all accidents and incidents and document the outcome and any action.
• We regularly and consistently monitor safety alerts and recalls, responding promptly to such notifications.
• We ensure our accident and incident reports are fit-for-purpose and train staff to effectively use them.
• We use systems and technology to provide our managers and staff with instant access to the latest accident and incident records, helping us to review current issues.
• We minimise the use of paper records where possible, avoiding increased risks from bad handwriting, omissions, and disorderly files.
• We empower staff to whistle blow and raise concerns about poor practice.
• Through our Duty of Candour, we are open and honest with the people we support about when things go wrong.
• We ensure that we update people, their families, staff and – where appropriate - others that engage with our service on the status of investigations and outcomes.
• We effectively communicate and document any changes to practice resulting from incidents and accidents, and the date these changes should be applied from.
• We ensure we learn from each and every accident, incident, near miss and event to continually improve safety at our service.
• Our lesson learned logs are regularly reviewed to identify trends and enable us to ensure associated improvements are embedded.

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