Safe · KLOE 1
Safety culture
Is there a positive and equitable safety culture, where risks are proactively managed, concerns are listened to, incidents are thoroughly investigated, and lessons are learned to improve care?
CQC wording, mental health care draft, pages 2 to 5.
Draft, not the current assessment framework
CQC's mental health care draft, published March 2026. The current quality statements remain in use.
CQC draft scope
What this proposed KLOE covers
Scope of this key line of enquiry and topic areas include:
- Safe culture
- Raising safety concerns
- Closed cultures
- Duty of candour
- Safety data by protected equality characteristics
- Use of force policy
- Trauma informed, psychologically safe culture
- Incident management
- Learning from lives and deaths (LeDeR) reports
How would this apply to your service?
The draft applies one framework across mental health care, but useful evidence depends on your service and people.
Source: CQC, Mental health care assessment framework, draft, 19 March 2026, pages 2 to 5. Contains public sector information licensed under the Open Government Licence v3.0.
CQC draft rating characteristics
How the draft describes each rating
These are CQC's draft characteristics. CQC says rating characteristics guide judgements, they are not a mechanical checklist.
Outstanding
- The service has an exemplary culture of openness, psychological safety and compassionate leadership. Specialist safety roles are highly visible, influential and act as system leaders, modelling expectations and empowering all staff to raise concerns that are valued and used to strengthen collective learning. People more likely to face safety risks are encouraged and enabled to participate.
- Reporting and learning systems are accessible, fair and responsive. All staff, including temporary workers, are trained and supported to use them, and learning from incidents, near misses and positive outcomes drives continuous improvement. Safety intelligence is treated as a critical asset for the service, with data reviewed continuously to identify and mitigate emerging risks.
- The service contributes to wider system improvement by learning from other organisations, sharing innovations and co-producing key policies with people who use services – including the annual update of the use-of-force policy informed by insights from incidents and risks.
Good
- Safety is a top priority that involves everyone, including staff and people using the service. There are clear roles and responsibilities for safety.
- A culture of safety and learning is embedded throughout all levels of the service. This is based on openness, transparency and learning from events that potentially put people and staff at risk of harm, or that have caused them harm. Staff understand health inequalities as a safety issue and know the steps to mitigate these.
- Any safety risks that result from inequalities, or affect particular groups of people, are identified and acted on.
- Care is monitored and assured to ensure its safety. Risks are proactively identified and mitigated. They are not overlooked or ignored but are dealt with willingly as an opportunity to put things right, learn and improve.
- Patient safety data is analysed by protected equality characteristics to identify any inequalities. The service takes appropriate action to address these inequalities.
- Everyone is encouraged and supported to raise safety concerns, including staff, people using the service, their families, visitors, carers and advocates. They feel confident that they will be treated with compassion and understanding, and will not be blamed, or treated negatively if they do so. The service takes appropriate action to keep everyone safe.
- The review of safety information, including safeguarding incidents, complaints and concerns, is prioritised to proactively identify, manage and control risks before safety incidents happen.
- Staff have a good understanding of the duty of candour. When an unintended or unexpected incident has occurred, staff are open and transparent with people and those close to them. There is a proportionate approach to recording, investigating and responding to them. Lessons are learned, enabling good practice to be continually identified and embedded, and lessons are shared internally and externally. Where harm has occurred, people are given full details of what happened, why, and what has been learned.
- The service is always open and transparent with people and staff. Where harm has occurred, people receive full details of what happened, why, and what has been learned.
- Leaders are aware of themes and trends in safety incidents and there is a leadership commitment to improving safety in the service.
- In mental health units, the policy on the use of force is updated annually, taking account of incidents and risks identified in the previous year.
Requires improvement
- Safety is recognised as important but is not consistently prioritised and does not always involve staff and people who use the service.
- Roles and responsibilities for safety are not clear to everyone and there may be gaps.
- The safety and learning culture is not fully embedded throughout all levels of the service. There is limited or inconsistent learning from incidents that could potentially expose people to the risk of harm, or that have caused them avoidable harm.
- There is limited analysis or understanding of safety risks that affect particular groups of people.
- There is limited monitoring of care to assure its safety. Risks of harm, including those in alerts and recalls, are inconsistently identified and managed.
- People and staff do not always feel supported to raise safety concerns. They do not always feel confident that they will be treated with compassion and understanding and may have concerns that they will be blamed or treated negatively.
- The review of safety information, including complaints and concerns, is inconsistent and safety risks are not always identified or mitigated to prevent harm.
- There are systems for reporting safety incidents and complaints, but these are not well-established and may not be used consistently. Learning from safety incidents and complaints is limited or inconsistent and does not always result in changes that improve care for others.
- When a notifiable safety incident has occurred, the service is not consistently open and transparent with people, those close to them and staff. People may receive some support, but it is insufficient or inconsistently provided.
- In mental health units: the policy on the use of force has not been updated to learn from identified risks.
Inadequate
- Safety is not prioritised within the service. Roles and responsibilities for safety are either not clear or do not exist and there is no clear accountability for safety.
- There is no effective culture of safety and learning. A lack of transparency and openness means that safety incidents may be ignored or not reported, and a closed culture is more likely to develop.
- There is no analysis or understanding of safety risks that affect particular groups of people, leading to higher risks of harm for some groups.
- There is a lack of monitoring and assurance of the safety of care. Risks of harm, including those in alerts and recalls, are not identified and managed.
- People and staff do not feel supported to raise safety concerns and there is evidence that when they have done so, they have not been treated with compassion and understanding and may have been blamed or treated negatively.
- Information about safety, including complaints and concerns, is not reviewed and safety risks are not identified or managed to prevent exposure to the significant risk of harm or harm.
- Systems for reporting safety incidents and complaints are either absent, not used or inappropriate. As a result, the service does not learn from incidents and complaints.
- When a safety incident has occurred, the service is not open or transparent with people, their loved ones and staff. People do not receive the support they need.
- In mental health unit’s there is no policy on the use of force that complies with relevant legislation.
Want to know how your service would fare?
Book a mock inspection run against the draft KLOEs, or call 020 8090 5346 to speak to one of our experts.