Standard 6: Reporting Serious Incidents

There should be a Serious Incident framework in place that describes the process and procedures to help ensure serious incidents are identified correctly, investigated thoroughly and, most importantly, lessons learnt to prevent the likelihood of similar incidents happening again.

6a. Is information on reporting incidents in your Safeguarding Policy and Annual Report?

Incidents include acts or omissions in care that result in:

  • unexpected or avoidable death or injuries resulting in serious harm.
  • injuries that required treatment to prevent
    • death or serious harm
    • abuse
    • Never Events
  • incidents that prevent (or threaten to prevent) an organisation’s ability to continue to deliver an acceptable quality of healthcare services.
  • incidents that cause widespread public concern resulting in a loss of confidence in healthcare services.

Incidents in health care are adverse events. These events have consequences to patients, families and carers, staff or organisations that are so significant or the potential for learning is so great, that a heightened level of response is justified.

There should be a process for those involved to describe the circumstances in which such a response may be required. This ensures that incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again.

Providers are responsible for the safety of their patients, visitors and others when on their premises, and must ensure robust systems are in place for recognising, reporting, investigating and responding to incidents and for arranging and resourcing investigations.

6b. Are managers assured that staff know when to make a safeguarding referral after an incident when they have reasonable cause for concern that the person is experiencing, or at risk of, abuse or neglect?

Your Health and Safety policy should state when and how people need to report any incident.

Keeping a tracker that monitors concerns including near misses, helps to identify what investigation has taken place to look at the root causes and lessons learned.  It is also an effective way to monitor trends and themes to make changes and involve all relevant staff, partner organisations and people who use the service.

CQC Key Lines of Enquiry (KLOEs)

CQC inspection teams will use the adult social care KLOEs framework to assess adult social care services, using appropriate prompts.