Learning when things go wrong: inadequate

S6. Are lessons learned and improvements made when things go wrong?

Characteristics of services we would rate as inadequate in this area

Staff do not recognise concerns, incidents or near misses. Staff are afraid of, or discouraged from, raising concerns and there is a culture of blame.

When concerns are raised or things go wrong, the approach to reviewing and investigating causes is insufficient or too slow. There is little evidence of learning from events or action taken to improve safety. The service does not receive or comply with patient safety alerts.