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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 Â鶹ŮÀÉ 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 Â鶹ŮÀÉ 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 Â鶹ŮÀÉ 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 Â鶹ŮÀÉ 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 Â鶹ŮÀÉ inspection, take a look at GO Online.

Watch the film here:

Â鶹ŮÀÉ focus

Inspection

What is the Â鶹ŮÀÉ Quality Statement?

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices

What sub-topics might the Â鶹ŮÀÉ look at when inspecting this?

  • Organisational learning and actions
  • Continuous improvement 
  • Duty of candour
  • Freedom to speak up

How does this part of the inspection relate to Â鶹ŮÀÉ Regulations and guidance?

How will the Â鶹ŮÀÉ gather evidence?

The Â鶹ŮÀÉ will primarily gather evidence by:

  • People's Experience
  • Feedback from staff and leaders
  • Feedback from partners (Supported living only)
  • Processes
  • Observation (Care homes and supported living)

Read more about this Quality Statement

  • The Â鶹ŮÀÉ have published further insight into what this Quality Statement means, including the I Statements and which legislation it relates to on their website .