CQC launches ‘Learning from safety incidents’ resources

The Care Quality Commission (CQC) has published a new series of resources to help those in charge of running health and care organisations ensure the safety and well-being of people using their services.

The key themes of the guidance cover problems with the quality and use of risk assessments, issues with documentation, issues with equipment and staff training. Each of the resources describe an issue 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, discussing 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.

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.”

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