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, primary care and community services draft V6.0, pages 3 to 5.
Draft, not the current assessment framework
CQC's primary care and community services draft V6.0, 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:
- Raising safety concerns
- Closed cultures
- Duty of candour
- Incident management
How would this apply to your service?
The draft applies one framework across primary care and community services, but useful evidence depends on your service and people.
Source: CQC, Primary care and community services assessment framework, draft V6.0, 19 March 2026, pages 3 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
- There is a proactive, systematic approach to managing safety, which is everyone’s top priority.
- Specialist safety roles are embedded and highly visible, acting as system leaders for safe practice. Staff feel genuinely empowered and trusted to raise safety concerns or propose improvements. Leaders demonstrate and reinforce that every safety concern is valued, responded to compassionately and used to strengthen collective learning.
- People more likely to face safety risks are encouraged and enabled to participate in decisions about risk relating to their care.
- Staff embed a culture of openness and collaboration at all levels of the organisation. Learning from incidents, near misses and what has gone well is prioritised to improve safe care.
- Hazards and risks are identified proactively, and these are assessed and mitigated thoroughly to avoid adverse outcomes. Solutions to risks are developed collaboratively and the effectiveness of the controls is monitored and measured.
- Processes for reviewing safety information and implementing required changes are fully embedded throughout all levels of the organisation. Data is continuously reviewed to proactively identify, manage, mitigate and control risks before incidents happen.
- There are well established systems for reporting safety incidents. Lessons are learned from safety incidents, resulting in improvements to the service. Learning is also shared externally to improve care for others. Leaders are knowledgeable about any themes or trends within their safety incidents. They are committed to taking action to keep people safe.
- All staff have a thorough understanding of the duty of candour and how important it is to achieve an open and transparent safety culture.
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 organisation. This is based on openness, transparency and learning from incidents that potentially put people and staff at risk of harm, or that have caused them harm. Care is monitored for assurance that it is safe.
- Risks of harm, including those highlighted in alerts and recalls, are proactively identified and mitigated to reduce harm. Risks are not overlooked or ignored. They are dealt with willingly as an opportunity to put things right, learn and improve.
- Any safety risks that result from inequalities, or affect particular groups of people, are identified and acted on.
- People and staff are encouraged and supported to raise safety concerns. If they do, they feel confident that they will be treated with compassion and understanding, and will not be blamed, or treated negatively. Appropriate action is taken to keep people safe.
- The review of safety information is used to proactively identify, manage, mitigate and control risks before safety incidents happen.
- There are clear systems for reporting safety incidents, in line with external requirements. These are used proactively to identify, manage and mitigate risks. Lessons are learned from safety incidents, resulting in improvements to the service. Leaders analyse safety incidents for themes and, where needed, take action to keep people safe.
- Staff have a good understanding of the duty of candour. When an incident has occurred, staff are open and transparent about it with people and those close to them. Where harm has occurred, people are supported. They are given full details of what happened, why, and what has been learned.
- There are systems to review local and national incident reports and incorporate any learning into the service.
Requires improvement
- Safety is recognised as important but is not consistently prioritised and does not always involve staff or 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 organisation. There is limited learning from incidents.
- There is limited monitoring of care and assurance of its safety. Risks of harm are inconsistently identified and managed.
- There is limited analysis or understanding of safety risks that affect particular groups of people.
- People and staff do not always feel supported to raise safety concerns. They may not feel confident that they will be treated with compassion or they may have concerns that they will be blamed or treated negatively.
- The review of safety information is inconsistent, and safety risks are not always identified or mitigated effectively.
- There are systems for reporting safety incidents, but these are not well established or may not be used consistently. Learning from safety incidents is limited or inconsistent and does not always result in changes that improve care for others.
- Staff have a limited understanding of the duty of candour. When a safety incident has occurred, staff are not consistently open about it with people and those close to them. People may receive some support when harm has occurred, but it is insufficient or provided inconsistently.
Inadequate
- Safety is not prioritised in the service. Roles and responsibilities for safety are not well established or are absent. There is no clear accountability for safety.
- There is no effective culture of safety and learning. A lack of transparency and openness means that incidents may be ignored or not reported, and a closed culture is more likely to develop.
- Care is not monitored and there is no assurance of its safety. Risks of harm are not identified or mitigated.
- There is no analysis or understanding of safety risks that affect particular groups of people, leading to higher risks of harm for some groups.
- People and staff do not feel supported to raise safety concerns. There is evidence that when they have raised safety concerns, they have not been treated with compassion or have been treated negatively.
- Safety information is not reviewed, and safety risks are not identified or mitigated to prevent harm.
- There are no systems for reporting safety incidents or the systems in place are not used effectively. As a result, the service does not learn from incidents.
- Staff have a poor understanding of the duty of candour. When a safety incident has occurred, staff are not open about it with people and those close to them. When harm has occurred, people do not receive the support they need.
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.