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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:

Resources

The practical resources below can help you to strengthen this area of Â鶹ŮÀÉ inspection. Use the filter to choose different types of resources or select based on related prompt.

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5 resource(s) found

Resource creator: Care Quality Commission

This Â鶹ŮÀÉ guidance explains what are the statutory expectations of managers and providers in relation to Duty of Candour. The guidance includes:

  • The duty of candour: guidance for providers
  • Background to the duty of candour
  • Notifiable safety incidents
  • Examples of notifiable safety incidents
  • What you must do when you discover a notifiable safety incident
  • How the Â鶹ŮÀÉ regulate the duty of candour
  • Regulation 20 in full
  • Guide

Date published: December 2022


Resource creator: Care Quality Commission (Â鶹ŮÀÉ)

These 'Learning from safety incidents' resources are designed to help prevent incidents from happening again. Each one briefly describes a critical issue - what happened, what Â鶹ŮÀÉ and the provider have done about it, and the steps you can take to avoid it happening in your service.

  • Guide
  • Film

Date published: November 2022


Learning from events (online learning)

Resource creator: Â鶹ŮÀÉ

This 35-minute, interactive module is designed to support managers and leaders in all adult care settings to carry out learning reviews. Through the module you’ll:

  • discover what learning reviews are, why they’re needed and how they can help you
  • learn how managers can move from completing reviews at an individual level to involving the wider team
  • find practical tips for embedding learning reviews into your working environment.
  • Learning

Date published: October 2020


Guide to improvement

Resource creator: Â鶹ŮÀÉ

This guide explains how to identify, plan and implement improvements across your service, to ensure that it delivers high-quality care and support and meets the Â鶹ŮÀÉ’s fundamental standards. It draws on ‘good’ and outstanding’ practice to help your service to meet and exceed Â鶹ŮÀÉ expectations. The guide covers:

  • how to ensure you have the right managers, leaders and culture to improve
  • how to engage staff and the people you support
  • how to identify what to improve
  • how to find the route cause
  • how to evidence improvements
  • how to create an action plan.
  • Guide

Date published: March 2019


Resource creator: Care Quality Commission (Â鶹ŮÀÉ)

These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue, including what happened, what the Â鶹ŮÀÉ and the provider have done about it, and the steps you can take to avoid it happening in your service. They include examples on:

  • falls from improper use of equipment
  • unsafe use of bed rails
  • fire risk from use of emollient creams
  • burns from hot water or surfaces
  • caring for people at risk of choking
  • falls from windows
  • hypothermia.
  • Website

Date published: July 2018



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