CQC launches 'Learning from safety incidents' guides

June 29, 2018

The independent quality regulator, the Care Quality Commission (CQC), has published a new series of resources – ‘Learning from safety incidents’ – to help those in charge of running health and care organisations ensure the safety and well-being of people using their services. 

Developed to share common critical issues initially identified from CQC’s criminal prosecution work against nine health and care providers that have failed to provide care and treatment in a safe way; each of the resources describe the issue – what happened, what CQC and the provider did about it and the steps that can be taken to prevent similar serious incidents from happening again in the future.

The key themes include: 

1. Problems with the quality and use of risk assessments

One care home had no proper system for assessing the risk to the health and safety of the people living there. This meant the provider failed to prevent a person with visual impairments from repeatedly falling in their bedroom. 

2. Issues with documentation  CQC - Learning from safety incidents

CQC has found evidence of wide-ranging documentation failures – including medication dosages and strengths, allergy information and medication administration times not being accurately recorded – as well as poor systems of stock managements leading to services running out of essential medicines. 

3. Issues with equipment 

One service failed to have adequate radiator covers in place which led to a case where a person living with dementia suffered burns after falling onto it. The provider had failed to provide radiator covers and pressure sensor mats to alert staff to a person getting out of bed.

4. Staff training

A person fell out of a shower commode chair because staff supporting them had not been informed about safety procedures and a related national safety alert. This could have been avoided if the provider had ensured staff were adequately trained.

Commenting on the new resources, Andrea Sutcliffe, CQC’s Chief Inspector of Adult Social Care, said: “When something goes terribly wrong in health and social care, the people affected, their families and carers often tell us, "I don’t want this to happen to anyone else”.  And we know that’s how staff and managers feel too.   

“Of course, it is important that CQC uses criminal enforcement powers to hold providers and managers to account when their failure to provide safe care and treatment has such tragic consequences.  But we also need to make sure we share the insight into what went wrong so that others can take practical action to avoid it happening to anyone else.

“That’s what these new resources are designed to do. They are short, to the point and describe simply what happened and what can be done differently.  I hope that they will be used by managers and staff across the country to improve the care they provide and make sure that the oft-repeated phrase that “lessons have been learned” is truly meaningful and does make a difference.”

The first five ‘Learning from safety incidents’ resources are available to view online at: www.cqc.org.uk/learningfromsafetyincidents 

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