Learning from Safeguarding Enquiries, Safety Incidents and Complaints

A learning opportunity is any event that provides an opportunity for learning.

It includes all the following:

1. A complaint from a person being supported, carer, family member or friend;
2. A ‘near miss’ safeguarding or health and safety incident;
3. Abuse or neglect (even if the local authority decided it did not need an enquiry);
4. A Safeguarding Adult Review (SAR);
5. Any incident that involved the police;
6. Any accident or injury to anyone;
7. A whistleblowing complaint;
8. CQC inspection or Commissioners Audit;
9. Quality assurance activity carried out by a manager or the registered person.

If the incident itself has been investigated by another organisation, such as the local authority or the police, any findings or recommendations for change that they make should form part of our own learning.

Note: Not all learning opportunities happen as a result of a negative event. We should also learn from positive things, such as compliments from people using services, carers or professionals. This allows good practice to be recognised, shared and implemented more widely across the whole service.

Learning together is an important part of an open culture, our team development and everyone's own personal development.

By coming together to talk honestly about what happened, without any fear of being blamed, we will develop our skills and become a stronger, more cohesive team.

Everyone will be able to share their experiences, views and ideas, and the solution that we find to any ongoing problems will be one that we have agreed on together. By learning together, we will be able to put changes into practice sooner and with more success than we would otherwise be able to do.

“We are in this together, therefore we’ll go through it together and be better together.”

Managers and the registered person will decide how to learn together. This could be through a whole team meeting, small groups or even on a one-to-one basis. The process does not matter so long as everybody has a chance to contribute to learning and nobody feels excluded.

Although the process of learning is an internal one, if it would be beneficial, the registered person can ask for a specialist to support the process. For example, if the event was a safeguarding incident relating to a pressure ulcer, it may be helpful for a district nurse to be involved.

The precise questions that we need to ask ourselves will be determined by the circumstances of the learning opportunity.

Most reflective learning follows 5 steps:

Step 1: Description

• When and where did this happen?
• Why were you/we there?
• Who else was there?
• What happened?
• What did you/we do?
• What did other people do?
• What was the result of this situation?

Step 2: Feelings

• What did you/we feel before this situation took place?
• What did you/we feel while this situation took place?
• What do you/we think other people felt during this situation?
• What did you/we feel after the situation?
• What do you/we think about the situation now?
• What do you/we think other people feel about the situation now?

Step 3: Evaluation

• What was positive about this situation?
• What was negative?
• What went well?
• What didn't go so well?
• What did you/we and other people do to contribute to the situation (either positively or negatively)?

Step 4: Conclusions

• How could this have been a more positive experience for everyone involved?
• If you/we were faced with the same situation again, what could you/we do differently?
• What skills do you/we need to develop, so that you/we can handle this type of situation better?
• What changes to you/we need to make to any plans, assessments etc.?
• What help do you/we need to make any changes?

Step 5: Action

This is the step where, based on the reflection that has taken place, actual actions and changes are agreed. This step should include who will do what and when by.

Changes should be implemented as soon as possible after they have been agreed. This could include updating individual care or support plans, risk assessments, making changes to staff rotas, arranging training etc.

The registered person should make sure that changes have been implemented in a timely way.

The whole staff team must be made aware when the changes have been implemented.

Changes must also be communicated to people using the service, if it is a change that is likely to impact in any way on the care and support being provided to them. For example, if a staff member is going to change or be there at a different time.

If the learning opportunity was a complaint, the person that made the complaint must be informed of the learning and changes made.

If the learning opportunity was a safety incident notifiable under the Duty of Candour, the relevant person must be notified of the learning and changes made.

If the learning opportunity was a poor CQC Inspection or Commissioners Audit, the CQC or commissioner must be advised of the learning and changes made.

If the learning opportunity was a safeguarding enquiry, if the local authority requested notification of changes made by the service, they should be notified.

It is good practice to keep a proportionate record of learning activity. This should be made with full regard for confidentiality and no unnecessary references to named individuals should be made.

Records of learning can demonstrate an open learning culture to people using the service, families, professionals, the Care Quality Commission, commissioners and any other regulatory body.