Incident & Accident Analysis Audit - Care Homes

Evidence to check

• • Current incident and accident reporting policy is available and reviewed
• • Policy explains what must be reported, by whom and within what timescale
• • Policy defines incident categories, severity levels, escalation routes and investigation standards
• • Staff can explain their responsibility to report incidents, accidents and near misses promptly

Evidence to check

• • Named registered manager, clinical lead, deputy manager or governance lead is documented
• • Responsibilities include incident review, investigation oversight, trend analysis, external reporting and action tracking
• • Deputy arrangements are in place for leave, weekends and out-of-hours incidents
• • Lead can explain current incident themes, open actions and high-risk cases

Evidence to check

• • Electronic or paper incident reporting system is available and understood
• • Staff on day, night, weekend, bank and agency shifts can access reporting routes
• • Incident forms capture all required information
• • System supports prompt escalation of serious incidents

Evidence to check

• • Manager or clinical lead reviews new incidents routinely
• • Serious or high-risk incidents are reviewed immediately
• • Review records show risk level, immediate actions and required follow-up
• • Unreviewed incidents are identified and escalated

Evidence to check

• • Governance minutes include incident trends, serious incidents, repeat incidents and learning
• • Actions are recorded with owners and deadlines
• • Themes are linked to quality improvement and risk register actions
• • Senior leaders monitor progress and effectiveness

Evidence to check

• • Incident forms prompt consideration of safeguarding, CQC notification, RIDDOR and duty of candour
• • Staff and managers understand that one incident may require multiple reporting routes
• • External reporting decisions and rationale are documented
• • Incident records cross-reference related safeguarding, CQC, RIDDOR, police or coroner records

Evidence to check

• • Incident categories include falls, medication, pressure damage, behaviours of distress, violence or aggression, equipment, IPC, environment and staffing
• • Severity levels are defined and used consistently
• • Staff understand how to categorise incidents
• • Trend reports use consistent categories over time

Evidence to check

• • Incident records include date, time, location and staff involved
• • Report time is compared with incident time
• • Delays in reporting are identified and followed up
• • Staff understand serious incidents must be escalated immediately

Evidence to check

• • Incident narratives describe what was seen, heard or reported
• • Records avoid assumptions, blame, labels or unsupported conclusions
• • Unconfirmed information is clearly described as suspected or reported
• • Managers provide feedback where recording quality is poor

Evidence to check

• • Records include first aid, observations, emergency services, GP or nurse review, family contact and environmental action where relevant
• • Immediate protective measures are documented
• • Escalation to senior staff is recorded
• • Actions taken are proportionate to the incident and risk

Evidence to check

• • Body maps are completed where relevant
• • Injury descriptions are clear and clinically accurate
• • Suspected injuries are updated when confirmed, such as X-ray-confirmed fracture
• • Care notes, hospital transfer records and incident forms are consistent

Evidence to check

• • Witness statements are obtained for serious, unclear, disputed or safeguarding-related incidents
• • Statements include staff, agency staff, visitors or other departments where relevant
• • Statements are factual and dated
• • Missing witness information is explained

Evidence to check

• • Resident account or view is recorded where possible
• • Communication support is used where required
• • Where the resident cannot give an account, the reason is documented
• • Resident distress, wishes or experience after the incident are considered

Evidence to check

• • Incident review considers environment, equipment, staffing, communication, health status, behaviour triggers and medication changes
• • Contributory factors are evidence-based
• • Factors are linked to preventative actions
• • Investigations avoid focusing only on the person directly involved

Evidence to check

• • Incident records link to care notes, MAR/TAR, ABC charts, body maps, maintenance logs, safeguarding forms or clinical reviews where relevant
• • Cross-references support a complete audit trail
• • Related records are updated promptly
• • Gaps between records are identified and corrected

Evidence to check

• • Near-miss reporting route is clear
• • Examples include almost-falls, medication near misses, equipment faults, missed care risks or environmental hazards
• • Near misses are included in trend analysis
• • Learning is shared before harm occurs

Evidence to check

• • System flags repeated falls, skin tears, refusals, behaviours of distress, medication issues or choking risks
• • Repeat incidents trigger care plan and risk assessment review
• • Resident-specific action plans are created
• • Effectiveness of actions is reviewed

Evidence to check

• • Low, moderate and high-risk investigation levels are defined
• • Serious or repeated incidents receive deeper review
• • Investigation depth is proportionate and justified
• • High-risk incidents receive senior sign-off

Evidence to check

• • RCA tools such as 5 Whys, fishbone or contributory factors analysis are used where appropriate
• • RCA considers systems, environment, communication, staffing, training and equipment
• • Findings are recorded clearly
• • Actions address root causes, not only immediate symptoms

Evidence to check

• • Incident reviews consider abuse, neglect, organisational neglect, peer-on-peer harm and self-neglect
• • Safeguarding referrals are made where threshold is met
• • Protective measures are recorded
• • Rationale is documented where safeguarding is considered but not referred

Evidence to check

• • Duty of candour screening is completed for relevant incidents
• • Records show openness, apology, explanation and actions to prevent recurrence where required
• • Resident or representative communication is documented
• • Duty of candour records are linked to the incident file

Evidence to check

• • Medication incident reviews consider drug, dose, route, timing, MAR process, staff competence and system factors
• • Pharmacist, GP or clinical lead input is sought where appropriate
• • Errors are reviewed for system failure as well as individual error
• • Actions reduce the risk of recurrence

Evidence to check

• • Falls reviews consider mobility, footwear, eyesight, continence, medication, orthostatic hypotension, environment and cognition
• • Post-fall observations and head injury checks are completed where needed
• • Falls risk assessment and care plan are updated
• • Repeat fallers are reviewed through a focused case review

Evidence to check

• • Reviews consider triggers, antecedents, behaviour, consequences and unmet needs
• • Pain, infection, communication, trauma, environment and sensory factors are considered
• • Behaviour support plans are updated after learning
• • Actions focus on prevention and least-restrictive support

Evidence to check

• • Review considers repositioning, pressure surfaces, nutrition, hydration, continence, moisture and documentation
• • Tissue viability advice is sought where appropriate
• • Avoidability and safeguarding considerations are documented
• • Care plans and equipment are updated promptly

Evidence to check

• • Equipment is quarantined immediately if safety is uncertain
• • Maintenance, LOLER, PAT, bedrail or mattress records are checked where relevant
• • Faults are reported and tracked to resolution
• • Equipment is not returned to use until safe

Evidence to check

• • Investigations review staffing levels, skill mix, agency use, fatigue, breaks and supervision
• • Rota and allocation records are checked where relevant
• • Staffing-related contributory factors are recorded honestly
• • Actions address staffing risks where identified

Evidence to check

• • Reviews consider lighting, flooring, clutter, signage, noise, temperature, call bells and access
• • Environmental checks are completed after relevant incidents
• • Photos or maintenance records are used where helpful
• • Environmental actions are tracked to completion

Evidence to check

• • Investigation summary states what happened, why it happened and what will change
• • Findings are supported by evidence
• • Responsible persons and timescales are clear
• • Outcome is signed off by an appropriate manager

Evidence to check

• • Weekly, monthly or quarterly incident reports are produced as defined by policy
• • Reports include number, type, severity, location, trends and actions
• • Reports are reviewed by leadership
• • Reports support decision-making rather than only data collection

Evidence to check

• • Trend reports break incidents down by category, unit, room, time of day and day of week
• • Staffing or skill mix is considered where relevant
• • Severity and harm level are analysed
• • Trend findings lead to targeted actions

Evidence to check

• • Top repeat incident residents, such as top fallers, are identified
• • Individual case reviews are completed
• • Care plans and risk assessments are updated
• • Actions are reviewed for impact

Evidence to check

• • Incident data is compared with dependency, acuity, rotas, agency use, complaints, safeguarding, audits and hospital admissions
• • Triangulation identifies wider system issues
• • Findings are discussed in governance meetings
• • Actions address root causes across systems

Evidence to check

• • Rates such as incidents per 1,000 bed days are used where useful
• • Changes in occupancy and dependency are considered
• • Comparisons avoid misleading raw number interpretation
• • Managers can explain whether incident rates are improving or worsening

Evidence to check

• • Analysis considers winter illness, heatwaves, outbreaks, staffing shortages, renovation works and holiday periods
• • Preventative plans are created for predictable seasonal risks
• • Actions are reviewed after seasonal pressures
• • Learning informs business continuity and staffing planning

Evidence to check

• • Hot spots such as bathrooms, corridors, dining rooms, medication rounds or night-time periods are identified
• • Environmental or staffing checks are completed
• • Mitigations are documented and implemented
• • Hot spot incident rates are reviewed after changes

Evidence to check

• • Incidents are reviewed for missed turns, late medication, hydration gaps, delayed call bell responses or missed observations
• • Missed care is escalated to management
• • Staffing, training or system causes are reviewed
• • Actions are tracked and checked for effectiveness

Evidence to check

• • Themes such as staffing gaps, equipment shortages, training needs or environmental risks are escalated
• • Provider-level minutes or reports evidence review
• • Resource decisions are documented where required
• • Escalated risks are monitored until resolved

Evidence to check

• • Learning is shared through meetings, handovers, safety huddles, supervision or bulletins
• • Learning focuses on prevention and systems improvement
• • Confidentiality is maintained
• • Staff can describe recent learning and what changed

Evidence to check

• • Staff feedback suggests incident reporting is encouraged and not punitive
• • Sudden drops in reporting are reviewed for possible under-reporting
• • Near-miss reporting is encouraged
• • Managers challenge non-reporting or delayed reporting constructively

Evidence to check

• • Debrief records are available for serious or distressing incidents
• • Staff emotional impact is considered
• • Support, supervision or signposting is offered
• • Debriefs identify learning as well as wellbeing needs

Evidence to check

• • Communication records show resident or representative contact where appropriate
• • Information shared is honest, timely and proportionate
• • Family contact preferences and consent are respected
• • Follow-up communication is documented

Evidence to check

• • Agency involvement is identified in incident records
• • Concerns or learning are communicated to the agency
• • Agency response and actions are recorded
• • Agency worker restrictions or do-not-return decisions are documented where needed

Evidence to check

• • Care plans and risk assessments are updated after incidents
• • Training materials or briefings reflect incident learning
• • Updates are time-stamped and attributable
• • Staff are informed of changed plans before providing further care

Evidence to check

• • Actions are specific, measurable, achievable, relevant and time-bound
• • Actions address causes and prevention
• • Action plans are proportionate to risk
• • Vague actions such as 'remind staff' are supported by stronger follow-up where needed

Evidence to check

• • Each action has an owner and target date
• • Overdue actions are flagged and escalated
• • Action progress is reviewed through governance
• • High-risk overdue actions trigger immediate management attention

Evidence to check

• • Completion evidence includes updated care plans, photos, training records, maintenance receipts, supervision records or audit results
• • Actions are not closed without evidence
• • Completed actions are checked by a manager
• • Records show who verified completion

Evidence to check

• • Follow-up checks assess whether incidents reduced or risk improved
• • Before-and-after data is used where possible
• • Actions are revised if they did not work
• • Effectiveness review is documented before final closure where appropriate

Evidence to check

• • Action plans consider systems, environment, staffing, training, equipment and communication
• • Individual performance issues are addressed fairly where relevant
• • Learning is not limited to telling staff to be more careful
• • Culture supports openness and improvement

Evidence to check

• • Equipment, staffing, training or environmental resource needs are costed or justified
• • Requests are escalated to provider or senior leadership
• • Interim safety controls are put in place
• • Resource decisions and outcomes are recorded

Evidence to check

• • Repeat incidents are compared with previous action plans
• • Managers review whether actions were completed and effective
• • Plans are revised where incidents continue
• • Persistent recurrence is escalated

Evidence to check

• • Incident records are screened for CQC notification triggers
• • Notification submissions and reference numbers are retained
• • Submission dates are timely
• • Notifications match incident records and investigation findings

Evidence to check

• • Safeguarding referrals are made where thresholds are met
• • Immediate protective actions are recorded
• • Local authority outcomes and actions are followed up
• • Safeguarding records are cross-referenced to incident files

Evidence to check

• • Staff injuries, dangerous occurrences or reportable events are screened for RIDDOR
• • RIDDOR submissions are recorded with reference numbers where applicable
• • Health and safety actions are linked to the incident investigation
• • RIDDOR decisions and rationale are documented

Evidence to check

• • Transfer documentation includes incident details, observations, medication list, allergies and baseline condition where relevant
• • Head injury observations or post-fall information are shared
• • Family or representative contact is recorded
• • Hospital outcome is followed up and added to the incident record

Evidence to check

• • Deaths, suspected crimes, unexplained injuries or serious incidents are escalated appropriately
• • Police or coroner reference numbers are recorded where available
• • Family communication is documented sensitively
• • Records remain factual and consistent across systems

Evidence to check

• • Contractual notification requirements are understood
• • Commissioner or local authority notifications are recorded
• • Evidence of submission and follow-up is retained
• • External reporting is aligned with CQC, safeguarding and duty of candour decisions

Evidence to check

• • Incident register includes incident type, severity, resident, date, time, location, outcome and escalation
• • Register is current and complete
• • Closed and open incidents are clearly identified
• • Register supports trend analysis

Evidence to check

• • Files include incident form, body map, witness statements, medical reviews, investigation notes and updated risk assessments where relevant
• • External referrals and notifications are included or cross-referenced
• • Action plan and completion evidence are present
• • Incomplete files are followed up

Evidence to check

• • Incident quality audits check completeness, objectivity, timeliness and escalation
• • Feedback is given to staff or managers where quality is poor
• • Common recording gaps are included in training or supervision
• • Audit results are reported through governance

Evidence to check

• • Care plan updates are completed promptly after incidents
• • Records show who updated the plan and why
• • Updates link directly to investigation learning
• • Staff are informed of the updated plan

Evidence to check

• • Incident closure criteria are defined
• • Actions are not left open after closure without rationale
• • Effectiveness review date is recorded where needed
• • Senior sign-off is completed for serious incidents

Evidence to check

• • Serious incidents are reviewed by registered manager, provider or clinical lead as appropriate
• • Sign-off confirms investigation quality and action plan adequacy
• • External reporting decisions are checked
• • Senior review challenges weak or incomplete investigations

Evidence to check

• • Recent dashboards or trend reports are available
• • Governance minutes show discussion, challenge and decisions
• • Actions are linked to identified trends
• • Progress and impact are reviewed

Evidence to check

• • Sampled incidents show timely reporting and escalation
• • Investigation depth matches severity and recurrence
• • Action plans are SMART and evidence-based
• • Follow-up confirms completion and effectiveness review

Evidence to check

• • Before-and-after comparisons are available where relevant
• • Targeted initiatives show measurable outcomes
• • Incident rates, severity or recurrence have reduced where actions were effective
• • Where improvement has not occurred, plans have been revised

Evidence to check

• • Staff can give specific examples of recent learning
• • Examples link to changed care plans, safer equipment use, improved documentation or changed routines
• • Learning is understood across shifts
• • Staff feel reporting leads to improvement rather than blame

Evidence to check

• • Audit checks reporting, investigation, external escalation, action completion and effectiveness review
• • Audit triangulates incidents with care records, staff feedback, resident outcomes and governance minutes
• • Audit identifies gaps between policy and practice
• • Actions strengthen prevention and reduce repeat harm

Evidence to check

• • Incident themes inform the risk register, training plan, staffing review and Quality Improvement Plan
• • Repeat risks are escalated to provider or senior leadership
• • Governance can evidence sustained monitoring of high-risk themes
• • The service demonstrates a transparent learning culture focused on safer care