The examples below provide insight into how other Good or Outstanding rated services are succeeding in this area of inspection.
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Using audits to improve personalised care
The provider used audits not only to monitor quality but also to deepen understanding of people's experiences and improve care. One audit analysed how people expressed their emotions, helping to identify themes in emotional distress and informing learning briefings for staff. These sessions highlighted opportunities to adapt practice, introduce additional training and strengthen support to reduce uncertainty and anxiety for people. Learning briefings also reviewed the quality of daily records and how well they reflected care plans, providing clear guidance on improving documentation. As a result, more detailed and accurate information was available to support decision-making and ensure healthcare professionals had the information they needed to deliver timely, coordinated care.
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Care provider: Catherine Tam Agency
Date published: July 2026
Learning from incidents to strengthen care
The service had clear systems for recording, investigating and learning from accidents and incidents. Staff used an electronic care record system to document incidents promptly, including observations, photographs, body maps and any medical advice sought. Head injuries were immediately escalated as medical emergencies, while senior staff and managers monitored every incident from beginning to end to ensure appropriate follow-up and care. Lessons learned were shared through handover briefings and a daily communication book, ensuring all staff understood any changes in people's needs or care. This consistent approach to recording, reviewing and communicating incidents helped strengthen learning across the service and supported safer, more responsive care.
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Care provider: Brook House Care 国产乱伦
Date published: July 2026
Embedding a no-blame learning culture
The service had embedded a well-established no-blame culture where staff felt confident to raise concerns, ask questions and discuss potential risks without fear of blame. This open approach enabled safety issues to be identified early, addressed promptly and shared as learning across the service. For example, following learning to further strengthen medicines safety, the service introduced a revised medicines administration protocol focused on improving accuracy, accountability and consistency. The changes included clearer recording systems, additional safety checks and enhanced guidance for staff, helping to reduce the risk of medicines errors and support safer, more consistent practice.
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Care provider: The Old Orchard
Date published: June 2026
Open culture, monthly incident reviews
The registered manager promoted an open culture within the home. The service kept records of accidents and incidents. Accidents and Incidents were reviewed monthly by the registered manager to determine any themes and actions needed. The provider had started to implement a new system to improve the effectiveness of accident reporting and analysis. Staff we spoke with told us the registered manager discussed learning from accidents and incidents with them.
Feedback from professionals working with the service told us the registered manager knew when to escalate concerns and worked with staff to review and support their care and development. One professional working with the service told us the registered manager was, “Very knowledgeable about safeguarding issues, knows when to escalate issues and will work with staff to review and support their care and development.”
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Care provider: Heathwood Care 国产乱伦
Date published: October 2024
Empowered residents, reflective learning culture
People were empowered and given opportunities to speak up if they had a concern. People living at Kings Court felt improvements would be made to their care if needed. People told us that if an incident happened, staff included them in discussions, so it did not happen again.
Staff told us that they had regular reflective supervision sessions to review what was working well, and what could be improved at the service. Staff gave examples of how the staff team had learnt from incidents. For example, one staff member said, “we have staff meetings where we discuss any concerns or incidents.”
The care manager told us they have monthly learning meetings with a range of staff from different roles and discuss incidents, learning, improvement, and actions from the last meeting. This meant there was a learning culture within the service.
There were clear and effective process in place to review incidents and then make improvements. Staff were provided with the opportunity to reflect after incidents to ensure learning and improvement could occur. Staff meetings allowed staff to reflect on what was working well, and what could be improved at the service.
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Care provider: Kings Court
Date published: September 2024
Incident review and family learning
Processes demonstrated people were consistently receiving exceptional care. There were systems in place to ensure staff fostered a culture of learning new skills to improve the lives of people. There were systems in place to ensure learning was identified from incidents and shared with staff. Learning was not just limited to the staff team. The registered manager told us that learning plays an important role in the residents and family meetings, where they have held workshops with families to help them learn more about the care, for example, modified diets, risk of choking and hydration. Staff recorded any accidents or incidents that occurred, and these were reviewed by senior staff to identify any action that could be taken to prevent a similar incident happening again. The management team told us they run daily reports to help identify if incidents have happened that they can learn from.
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Care provider: Manor Lodge
Date published: September 2024
Open safety culture; reflective teamwork
The registered manager and managing director had successfully shifted the culture from a blame culture to one that was open and transparent and about learning rather than blame. This was reflected in staff survey feedback and in the reduction of reoccurring accidents and incidents.
The service had a proactive and positive culture of safety based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Quality monitoring systems such as audits were used effectively to highlight areas of improvement and identify trends. For example, audits were reviewed daily to ensure call times and the length of time staff stayed with people were consistent. This had reduced complaints and improved people’s daily care experience.
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Care provider: Premier Community
Date published: July 2024
Learning from falls
In this from the Care Exchange podcast, Ben Miller talks about how following an increase in falls, he convened a task force to create a falls prevention project.
You can listen to the full podcast . Access our whole Care Exchange series here.
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Care provider: Castleford House
Date published: December 2022
Using Lesson-learned meetings to share national guidance
To disseminate information amongst staff, this service shared learning from incidents through emails and ‘lessons-learned’ meetings. ‘Lessons-learned’ meetings happen monthly, and urgently after any serious incidents. Throughout the pandemic, these meetings have been held online. To supplement these ‘lessons-learned’ meetings, the service also share relevant information from NICE, CQC and the Adult Social Care Ombudsman, collated by registered managers.
See also:
Care provider: Anonymous
Date published: January 2022
Learning from residents to improve nutrition and hydration
We’re constantly looking at ways to improve and learning from mistakes, suggestions or near misses.
Our residents wanted to review our nutrition and hydration at the home, so we formed a ‘residents food committee’ with several residents, as well as the head chef, manager and other key staff.
This is very helpful, since we can ensure the residents are getting what they want, when they want it, and has developed an even more open approach to suggestions and feedback about food and nutrition within the home.
We also recently had a resident who was admitted to hospital and there were some signs of dehydration. We immediately put in place supervision and training for staff to undertake training around maintaining hydration to ensure this risk could be avoided in the future.
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Care provider: Valerie Manor
Date published: November 2021