Incident & Accident Analysis Audit - Care Homes

Q1 | Unanswered

Is there a current Incident/Accident Reporting policy that defines reporting thresholds, responsibilities, timescales, and investigation standards?

Q2 | Unanswered

Is there a named lead responsible for incident governance (e.g., Registered Manager/Clinical Lead) with deputy cover arrangements?

Q3 | Unanswered

Is there a clear system for recording incidents/accidents (electronic/paper) that is accessible across shifts and supports timely reporting?

Q4 | Unanswered

Are incidents reviewed daily/weekly by leadership with documented oversight and prioritisation of risk?

Q5 | Unanswered

Are incident trends and learning reviewed in governance/quality meetings with minutes and decisions recorded?

Q6 | Unanswered

Are incident processes linked to safeguarding, CQC notifications, RIDDOR (where applicable), coroner/police processes, and duty of candour triggers?

Q7 | Unanswered

Is there a consistent incident classification framework (falls, medication, pressure damage, behaviours, violence/aggression, equipment, IPC, environment, staffing)?

Q8 | Unanswered

Are incidents reported promptly (same shift where possible) with clear date/time/location and staff involved recorded?

Q9 | Unanswered

Are descriptions factual and objective (what happened, what was observed) without blame or speculation?

Q10 | Unanswered

Are immediate actions recorded (first aid, escalation, medical review, family contact, observation levels, environmental changes)?

Q11 | Unanswered

Are injuries documented accurately (including body maps where relevant) and updated when confirmed (e.g., X-ray confirmed fracture)?

Q12 | Unanswered

Are witness statements captured when relevant (including agency staff and other departments)?

Q13 | Unanswered

Are residents’ views captured where possible, and where not possible is this noted (e.g., cognitive impairment)?

Q14 | Unanswered

Are contributing factors recorded (environment, equipment, staffing, communication, health status, behaviour triggers, medication changes)?

Q15 | Unanswered

Are incidents cross-referenced to related records (care notes, MAR/TAR, ABC charts, maintenance logs, safeguarding forms)?

Q16 | Unanswered

Are near-misses recorded and analysed, not only events with injury/harm?

Q17 | Unanswered

Are repeat incidents for the same resident clearly flagged to trigger review (e.g., repeated falls, repeated skin tears, repeated refusals)?

Q18 | Unanswered

Are incidents investigated proportionately based on severity and recurrence (low/moderate/high risk)?

Q19 | Unanswered

Is an RCA approach used for serious or repeated incidents (e.g., 5 Whys, fishbone, contributory factors analysis)?

Q20 | Unanswered

Are safeguarding thresholds considered and referrals made where abuse/neglect is suspected (including organisational neglect)?

Q21 | Unanswered

Are duty of candour requirements considered and documented where harm occurred (openness, apology, explanation, actions)?

Q22 | Unanswered

Are medication incidents investigated with pharmacy/clinical input where appropriate (system failure vs human error)?

Q23 | Unanswered

Are falls investigated with multifactorial review (orthostatic hypotension, vision, footwear, mobility aid fit, environment, toileting)?

Q24 | Unanswered

Are behaviours-related incidents investigated using ABC or functional assessment principles (triggers, prevention, de-escalation)?

Q25 | Unanswered

Are pressure damage incidents investigated with tissue viability lens (repositioning, surfaces, nutrition, moisture, documentation)?

Q26 | Unanswered

Are equipment-related incidents investigated with maintenance/LOLER/PAT checks and immediate equipment quarantine if needed?

Q27 | Unanswered

Are staffing factors considered (skill mix, staffing levels, agency use, fatigue) and evidenced rather than assumed?

Q28 | Unanswered

Are environmental factors considered (lighting, flooring, clutter, signage, noise, temperature) with documented checks?

Q29 | Unanswered

Are investigation outcomes clearly recorded (what happened, why, what will change, who is responsible, by when)?

Q30 | Unanswered

Is there a structured incident dashboard or summary report produced at defined intervals (weekly/monthly)?

Q31 | Unanswered

Are trends analysed by type, location/unit, time of day, day of week, staff mix, and severity level?

Q32 | Unanswered

Are repeat residents identified and case reviewed (e.g., top 5 fallers) with individualised action plans?

Q33 | Unanswered

Are trends triangulated with other data (dependency/acuity, staffing rotas, complaints, safeguarding, audits, hospital admissions)?

Q34 | Unanswered

Are incident rates normalised where appropriate (e.g., incidents per 1,000 bed days) to support meaningful comparison over time?

Q35 | Unanswered

Are seasonal and situational trends identified (winter illness, heatwaves, staffing shortages, outbreaks, renovation works)?

Q36 | Unanswered

Are ‘hot spots’ identified (certain corridors, bathrooms, times during medication rounds) and mitigations documented?

Q37 | Unanswered

Are patterns of missed care identified via incidents (pressure area misses, hydration, call bell delays) and escalated?

Q38 | Unanswered

Are recurring themes escalated to provider level where relevant (training gaps, equipment needs, staffing establishment changes)?

Q39 | Unanswered

Is learning from incidents shared with staff (team meetings, handovers, safety huddles, bulletins) in a no-blame way?

Q40 | Unanswered

Are staff supported to report incidents without fear, and is under-reporting monitored (e.g., sudden drops in reporting)?

Q41 | Unanswered

Are reflective debriefs held after significant incidents, including staff wellbeing support where needed?

Q42 | Unanswered

Are residents/families informed appropriately about incidents and outcomes, with communication documented?

Q43 | Unanswered

Are agencies included in feedback/learning where incidents involve agency staff, and is this communicated to the agency?

Q44 | Unanswered

Are lessons learned used to update care plans, risk assessments, and training content promptly?

Q45 | Unanswered

Do incident investigations generate clear action plans with SMART actions (specific, measurable, achievable, relevant, time-bound)?

Q46 | Unanswered

Are actions assigned to named owners with deadlines and escalation if overdue?

Q47 | Unanswered

Are actions tracked to completion with evidence (photos, training records, updated care plans, maintenance receipts)?

Q48 | Unanswered

Is effectiveness reviewed after implementation (did falls reduce? did errors stop?) with documented evaluation?

Q49 | Unanswered

Are actions proportionate to risk and focused on prevention (system changes) rather than only individual blame?

Q50 | Unanswered

Where actions require resource (equipment purchases, staffing increases), is business justification documented and escalated?

Q51 | Unanswered

Are repeat incidents used to test whether previous actions worked, and if not, are plans revised?

Q52 | Unanswered

Are CQC notifications submitted accurately and timely where incidents meet criteria, with evidence retained?

Q53 | Unanswered

Are safeguarding referrals submitted where required, with protective measures documented and outcomes followed up?

Q54 | Unanswered

Are RIDDOR reports made where applicable (e.g., staff injuries, dangerous occurrences) and recorded appropriately?

Q55 | Unanswered

Are hospital transfers documented clearly with relevant information shared (falls details, head injury obs, medication lists)?

Q56 | Unanswered

Are coroner/police processes followed where required, with clear documentation and family communication records?

Q57 | Unanswered

Are commissioners/local authority notifications completed where required by contract, with evidence retained?

Q58 | Unanswered

Is there an incident log/register capturing incident type, severity, resident, date, location, outcome, and escalation actions?

Q59 | Unanswered

Are incident files complete with linked documents (body maps, witness statements, medical reviews, risk assessment updates)?

Q60 | Unanswered

Are audits undertaken to check incident report quality (completeness, objectivity, timeliness) with feedback to staff?

Q61 | Unanswered

Are incident-related care plan updates time-stamped and clearly attributable to the incident outcome?

Q62 | Unanswered

Are incidents closed only when actions are completed and effectiveness checks planned or completed?

Q63 | Unanswered

Is there evidence of senior review/sign-off for serious incidents and investigations?

Q64 | Unanswered

Can the home provide the last 3–6 months of incident trend reports/dashboards with minutes showing review and decision-making?

Q65 | Unanswered

Can a sample of incidents demonstrate: prompt reporting, proportionate investigation, clear action plans, and follow-up evidence?

Q66 | Unanswered

Can the home evidence reductions/improvements linked to actions taken (before/after comparisons, targeted initiatives)?

Q67 | Unanswered

Can staff describe how learning is shared and how it changes day-to-day practice (specific examples)?