- Published: 15/09/2022
- Contains public sector information licensed under the Open Government Licence v3.0.
Over the next few months, we will be exploring the CQC key lines of enquiry by each question and sharing resources we think you might find useful.
Is your service safe? Are lessons learned and improvements made when things go wrong?
Questions
S6.1 Do staff understand their responsibilities to raise concerns, to record safety incidents, concerns and
near misses, and to report them internally and externally, where appropriate?
S6.2 What are the arrangements for reviewing and investigating safety and safeguarding incidents and events when things go wrong? Are all relevant staff, services, partner organisations and people who use services involved in reviews and investigations?
S6.3 How are lessons learned and themes identified, and is action taken as a result of reviews and investigations when things go wrong?
S6.4 How well is the learning from lessons shared to make sure that action is taken to improve safety across relevant parts of the service? Do staff learn from reviews and investigations by other services and organisations?
S6.5 How effective are the arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations or reviews?
Ratings characteristics
- Outstanding
People are protected by a strong, empowering and distinctive approach to safety and a focus on openness, transparency and learning when things go wrong.
- Good
People are protected from avoidable harm and abuse. Legal requirements are met.
The service will always support people to keep themselves and their belongings safe and secure.
- Requires improvement
The service has an inconsistent approach that sometimes puts people’s safety, health or wellbeing at risk. There is an increased risk that people are harmed or there is limited assurance about safety. Regulations may or may not be met.
- Inadequate
A service may have some areas of safe practice, but in general, people are not safe. Normally some regulations are not met.
Potential sources of evidence
People & their carers, friends and relatives:
- Experience of raising concerns.
- Experience of how serious incidents or near misses have been dealt with.
- Experience of involvement in investigations and reviews.
- Experience of Duty of Candour arrangements and notifications.
- Satisfaction with outcomes when things have gone wrong.
CRM (Customer Relationship Management)
- Share your experience forms.
- Notifications.
- RIDDOR.
- Coroners Reports.
- Information of concern enquiries.
Organisations
Feedback about whether/how:
- The service responds to serious incidents or near misses, including investigations,
reporting, recording, learning and improvement. - The service works with other agencies when serious incidents and near misses
occur.
Staff
- Awareness of relevant policies, guidance, procedures, standards and responsibilities
and how to appropriately apply in practice. - Experiences of training, support & guidance in practice.
- Experiences of organisational expectations, culture and approach to learning and
improvement. - How staff contribute to preventing & responding to serious incidents and near misses
Leaders & Managers
- Understanding of responsibilities under Duty of Candour.
Observation
- Meetings that consider incidents and near misses.
Records and policies
- Complaints and compliments.
- Incident and ‘near miss’ policies and records, including alerts, investigations, outcomes and improvement plans.
- Staff induction, training, support, development and disciplinary records.
- Communications with staff.
- Duty of Candour policies and procedures.
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