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Single Assessment Framework version

All services - change

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:

Recommendations

These recommendations act as a checklist to what the Â鶹ŮÀÉ will be looking for. Â鶹ŮÀÉ has reviewed hundreds of inspection reports and identified these recommendations as recurring good practice in providers that meet Â鶹ŮÀÉ expectations.

The Â鶹ŮÀÉ is non-prescriptive, which means they don’t tell you what must be done in order to meet their Quality Statement. These recommendations are not intended to be a definitive list and some recommendations might not be relevant to your service. We hope they help you reflect on what evidence you might wish to share with the Â鶹ŮÀÉ.

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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Â鶹ŮÀÉ Ltd, West Gate, Grace Street, Leeds, LS1 2RP. Registered company no. 3866683. Registered in England charity no. 1079836.
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