How do you evidence a learning culture to CQC, from incident to change?

To evidence a learning culture to CQC, show real incidents that were reported openly, investigated, explained to the person affected under the duty of candour, turned into a change in practice, and checked afterwards. This is what CQC's Learning culture quality statement under Safe describes, and it judges it from people's experience, staff feedback and your processes.

What CQC asks for

Learning culture is the first quality statement under Safe. For independent doctors and clinics, CQC describes it as a proactive and positive culture of safety based on openness and honesty, where concerns are listened to, safety events are investigated and reported thoroughly, and lessons are learned and embedded. It usually looks at people's experience, feedback from staff and leaders, and processes.¹

Processes evidence explicitly includes findings and learning from safety incidents.² Staff evidence includes staff surveys, interviews with staff and leaders, and whistleblowing.³ So an inspector will read your records, and then ask your team.

From incident to change, step by step

1. Report it the same day. Anyone can raise it, without fear. Record what happened, when and who was involved.
2. Secure the facts. Take the sequence of events from the record, not from memory. Who did what, and when.
3. Apply the duty of candour. For a notifiable safety incident, tell the person face to face as soon as reasonably practicable, apologise, give a true account, explain next steps, follow up in writing, and keep a secure written record.
4. Find the cause in the system. Ask what made the error possible, not who made it. Look at handovers, checks and defaults.
5. Change one thing. A specific change to a process, a check or a default, with an owner and a date.
6. Check it held. Look again after a set period. Did the change stick, and did similar incidents fall?
7. Tell the team. Share what was learned, so people can describe it in their own words at interview.

The candour steps are CQC's own, and saying sorry is not an admission of liability.⁴⁵ Notify CQC as well when an incident falls within its notification list, such as a serious injury or the death of a person using the service.⁶

1. Incident ______ Date ______ Reported by ______
2. Sequence of events, from the record ______
3. Notifiable safety incident, yes or no ______ Candour completed on ______
4. System cause ______
5. Change made ______ Owner ______ By ______
6. Checked on ______ Did it hold ______
7. Shared with the team on ______

Copy template

What Outstanding learning culture evidence includes

• Near misses reported as freely as harm, a sign that people feel safe to speak up.
• Changes that reach the system, a new check or a safer default, not only a reminder email.
• A trend you can show, with repeat incidents falling.
• Staff at every level who can describe a recent change and why it happened.

Questions

What is a notifiable safety incident?

A specific category defined in the duty of candour regulation. CQC's guidance explains the definition and gives examples. If an incident qualifies, the professional duty alone is not enough.

Is an apology an admission of liability?

No. CQC's guidance is explicit that apologising is not an admission of liability.

How does wai support an incident review?

wai gives your incident process the facts, the audit trail of who did what and when, from the patient record, so every review starts from an exact timeline.

Sources

1. 1CQC, 2024Independent doctors, evidence categories for SafeRead source
2. 2CQC, 2024Evidence categories, processesRead source
3. 3CQC, 2024Evidence categories, feedback from staff and leadersRead source
4. 4CQC, 2025Regulation 20, Duty of candourRead source
5. 5CQC, 2022What you must do when you discover a notifiable safety incidentRead source
6. 6CQC, 2026NotificationsRead source

Written by the wai team from Care Quality Commission guidance, checked on 15 October 2026. This is guidance, not legal advice. CQC does not endorse wai or any software.