Registered Managers - Learning from Serious Incidents and Near Misses CQC Compliance
Registered Managers - Learning from Serious Incidents and Near Misses CQC Compliance
Governance, Investigation & CQC Compliance for Registered Managers
Enough resources for a one day workshop or use the resources for a training session.
All files editable.
Presentations x 2 (One in Sections, the other learning activities for each section), Word Document handout and 9 Word Document Learning Activities (one of which are reflection/discussion Questions).
Overall Aim:
To equip Registered Managers with the knowledge, skills and governance tools required to effectively manage serious incidents and near misses, embed a learning culture and demonstrate regulatory compliance and continuous improvement.
Learning Objectives:
By the end of the session, learners will be able to:
Define serious incidents and near misses within adult social care.
Explain their legal and regulatory responsibilities as a Registered
Manager.
Apply a structured approach to incident investigation.
Conduct basic root cause analysis.
Develop SMART action plans that prevent recurrence.
Demonstrate evidence of organisational learning for inspection.
Promote a just and open reporting culture.
Presentation 1 (137 Slides)
Overall Aim
Learning Objectives
Section - Setting The Context
Setting The Context
Why Learning from Incidents Matters
It Prevents Repeat Harm
It Demonstrates Good Governance (Regulation 17)
It Protects Your Registration
It Strengthens Inspection Outcomes
It Creates a Culture of Safety
The Cost of Not Learning – What Happens
When Learning Fails?
Real Case Example
Real Case Example - Outcome
Real Case Example – What Went Wrong
What the Regulator Identified
Regulatory Outcome
Key Learning Points
SECTION - Definitions & Thresholds
What is a Serious Incident?
What is a Near Miss?
What Must Be Reported?
Common Confusion Areas in Social Care
Common Grey Areas
Section - Regulatory & Legal Responsibilities
Role of the Registered Manager
Regulation 12 – Safe Care & Treatment
Regulation 17 – Good Governance
Duty of Candour Requirements
Documentation Expectations During Inspection
What Inspectors Commonly Say
SECTION - Immediate Incident Management
Immediate Actions After An Incident
Securing Evidence
Supporting Staff & Service Users
Communication & Escalation Pathways
SECTION - Investigation Process
Why Investigations Fail
Blame Culture vs Learning Culture
Investigation Framework Overview
Building a Timeline
Gathering Statements
Reviewing Documentation
Identifying Contributory Factors
SECTION - Root Cause Analysis
What is Root Cause Analysis?
The 5 Whys Method
Human Factors in Care Settings
Systems vs Individual Error
SECTION - Action Planning and Preventing Reoccurrence
Turning Findings Into Action
SMART Action Planning
Weak vs Strong Actions
Embedding Change in Practice
Section - Embedding Organisational Learning
Why Trend Analysis Matters
What Should Be Themed?
What Inspectors Want To See
Learning Logs
Staff Feedback & Supervision
Cultural Indicators of Embedded Learning
Governance Meetings & Board Reporting
Provider/Board Reporting
Section - Inspection Readiness
What Inspectors Look For - Well-Led and Safe Key Questions
Evidence of Learning
Common Inspection Pitfalls
Mock Inspection Question Practice
Model Answer Structure for Managers
Example Model Answer (Falls Scenario)
Section - Creating a Just Culture
Psychological Safety
Why It Matters in Social Care
Research Insight
What Inspectors Observe
Why Staff Don't Report
Leadership Behaviours That Encourage Reporting
Handling Staff Involved in Errors
Emotional Reality
Structured Approach to Staff Support
Balancing Accountability With Fairness and The Three Behaviour Categories
Leadership Decision Test - Ask
Closing Message
References and Further Resources
Presentation 2 (Learning Activities) (45 Slides)
Overall Aim
Learning Objectives
Section - Setting the Context
Interactive Discussion Prompt
Reflective Discussion Questions
Section - Definitions & Thresholds
Activity - Reporting Threshold Scenarios
Scenario 1: Medication Error (No Harm)
Scenario 2: Repeated Medication Errors (Same Staff Member)
Scenario 3: Resident Fall with Serious Injury
Scenario 4: Pressure Ulcer (Category 3)
Scenario 5: Staff Injury (Broken Arm During Moving & Handling)
Scenario 6: Unwitnessed Death Overnight
Section - Regulatory & Legal Responsibilities
Reflection/Discussion Question
Section - Immediate Incident Management
Mini Exercise: “First 24 Hours Checklist”
Model First 24 Hours Checklist
Debrief Questions
Section - Investigation Process
Timeline-Building Case Study Exercise
Activity Instructions
Model Timeline Example
Expected Contributory Factors
Debrief Question
Section - Root Cause Analysis
Interactive Activity: Applying the 5 Whys
Immediate Cause and 2) The 5 Whys
3) Root Cause and 4) Preventative Action
Section - Action Planning and Preventing Reoccurrence
Write a SMART Action Plan
SMART Action Plan Example
Debrief Questions and Conclusion
Section - Embedding Organisational Learning
Reflection/Discussion Questions
Section - Inspection Readiness
Practice Exercise
Reflection/Discussion Questions
Section - Creating a Just Culture
Reflective/Discussion Question
Reflection/Discussion Exercise
Word Documents
Post Training Handout
Discussion Exercise Blame or Learning
Activity Discussion How Do You Share Learning Beyond the Incident File
Activity Practical Exercise
Activity Write a SMART Action Plan
Activity Applying the 5 Whys
Activity Timeline Building Case Study Exercise
Mini Exercise First 24 Hours Checklist
Activity Reporting Threshold Scenarios
Reflection or Discussion Questions (List)
HSC Training Link
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