Care home incident, audit systems

Incident reports of any violent or aggressive behaviour by either people with learning disabilities and autistic people or staff should be analysed and trend data reported on every HSCT Board’s quality and safety dashboard. In private and third sector care a similar system must be in place.

A quarterly multidisciplinary audit of 10% of safeguarding files per ward or residential unit should be conducted. Findings must be integrated with incident data and reported to the Executive Team, NEDs and the Strategic Planning and Performance Group (SPPG).

HSCT Board audit committees should consider all internal audit recommendations and require directorates to provide updates on implementation three months, six months and one year after the internal audit report is received, and three monthly thereafter if still not fully implemented.

Health Boards should ensure that OCT3 reports provide sufficient details of the key factors in the spread of infection to allow a proper audit to be carried out.