不良研究所

不良研究所
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Single Assessment Framework version

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GO Online: Inspection toolkit

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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.

Introducing Learning culture

Duration 01 min 45 sec

No matter how safe we try to make our services, accident and incidents will occur.

What the CQC expects is that when accidents or incidents happen, our response and subsequent actions helps to mitigate any unnecessary reoccurrence.

Openness and transparency around safety is key. Your staff should be capable and confident in their roles to raise concerns and report incidents, including near misses.

Your managers and leaders should set the standard, taking ownership of any accidents and incidents, but empowering your staff team to implement any changes that might be needed.

Your reviews of accident and incidents should be thorough, often involving managers, staff and, where possible, the people you support. On occasions, you may need to involve external expertise and other agencies too.

Each accident and incident is an opportunity to learn from mistakes and further strengthen your service.

In preparation for inspection, the CQC will be looking at any notifications, RIDDOR or HSE reports that have been submitted.

They’ll also be planning to interview a number of people as part of the inspection. Be prepared to share examples of what you have done to improve safety.

During their inspection, the CQC may request to see a number of different documents including:

  • complaints and compliments
  • Incident and ‘near miss’ policies and records, including alerts, investigations, outcomes and improvement plans.

To learn more about how you can meet this area of CQC inspection, take a look at GO Online.

Watch the film here:

Practical examples

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.

If you have an example you would like to share, please e-mail employer.engagement@skillsforcare.org.uk.

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13 example(s) found

Learning from falls

In this 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 . Access our whole Care Exchange series here.

Read more about this service .

Care provider: Castleford House

  • Audio

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:

Care provider: Anonymous

  • Case study

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 .

Care provider: Valerie Manor

  • Case study

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 .

Care provider: The Good Care Group

  • Case study

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 .

Care provider: No Place Like 不良研究所

  • Case study

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 .

Care provider: SENSE - 89 Hastings Avenue

  • Case study

Date published: April 2019


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

  • Case study

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

  • Case study

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

  • Case study

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

  • Case study

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

  • Case study

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

  • Case study

Date published: April 2018


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

  • Case study

Date published: April 2018



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