NHS Safety Culture: Opening the door to change

Care Quality Commission | December 2018 | NHS Safety Culture: Opening the door to change

The CQC collaborated with NHS Improvement to look at issues in NHS trusts that contribute to Never Events taking place. These are incidents with the potential to cause serious patient harm or death that are wholly preventable if national guidance or safety recommendations are followed.

 

opening the door
Image source: cqc.org.uk

Their review sought to answer 4 questions:

  • How do trusts regard existing guidance to prevent Never Events?
  • How effectively do trusts use safety guidance?
  • How do other system partners support the implementation of safety guidance?
  • What can we learn from other industries?

To this end the CQC visited 18 NHS trusts (both acute and mental health) during April and June 2018. They conducted one-to-one interviews, visited different services and reviewed policies and procedures.

CQC also consulted aviation, nuclear and fire and rescue industries to understand other safety-critical industries’ approach to safety.

Although patient safety alerts are generally seen as an effective way to share safety guidance, the context in which they are landing creates challenges for trusts. The report identifies challenges faced by trusts, by the health system as a whole, and in educating and training staff (Source: CQC).

Full news release from CQC 

Opening the door to change 

Opening the door to change Summary

Related:

NHS Improvement Never events data 

CQC publish findings of health and social care services in Leeds

Care Quality Commission | December 2018 | CQC publish findings of health and social care services in Leeds

The Care Quality Commission (CQC) has published its findings following a review of health and social care services in Leeds.

This report is one of a number of targeted local system reviews looking specifically at how older people move through the health and social care system, with a focus on how services work together.volunteer-2055015_640.png

As part of the review, CQC sought the views of a range of people involved in shaping and leading the system and those responsible for directly delivering care, as well as people who use services, their families and carers.

Reviewers found that there was a good voluntary, community and social enterprise sector in Leeds with many opportunities for people to receive support, particularly for people at risk of social isolation and loneliness.

The review found that when older people attended hospital, there was a higher chance than the England average that they would be admitted, and once people were admitted it was difficult for them to return home with support. The review team also found that some people had poor experiences when they were in hospital.

The report concludes that system leaders in Leeds had a shared vision that was supported and understood across health and social care organisations, with a shared understanding of the challenges ahead (Source: CQC)

The full report is available from CQC

Local system review: Leeds 

NHS safety culture and the need for transformation

Opening the door to change: NHS safety culture and the need for transformation | The Care Quality Commission  

This report examines the underlying issues in NHS trusts that contribute to the occurrence of Never Events and the learning that can be applied to wider safety issues. Never Events are incidents with the potential to cause serious patient harm or death that are wholly preventable if national guidance or safety recommendations are followed.

door to change
Image source: http://www.cqc.org.uk

The review sought to answer 4 questions:

  • How do trusts regard existing guidance to prevent Never Events?
  • How effectively do trusts use safety guidance?
  • How do other system partners support the implementation of safety guidance?
  • What can we learn from other industries?

The report finds that too many people are suffering unnecessary harm because NHS staff are not supported by sufficient training, and because the complexity of the current patient safety system makes it difficult for staff to ensure that safety is an integral part of everything they do.

Full report: Opening the door to change: NHS safety culture and the need for transformation

Technology in care

Care Quality Commission | November 2018 | Technology in care

The Care Quality Commission (CQC) have published a series – Technology in care- which shows how technology is used, the benefits of its usage and it also includes examples of best practice .

Introduction: How technology can support high-quality care

Using surveillance in your care service

Check the way you handle personal information meets the right standards

Find out if you need consent to use technology as part of someone’s care

 

CQC inspection regime having an impact but there is room for improvement

Care Quality Commission (CQC)’s ‘Ofsted-style’ inspection and rating regime is a significant improvement on the system it replaced, but it could be made more effective, according to the first major evaluation of the approach introduced in 2013 | The Kings Fund

This research, carried out by The King’s Fund and Alliance Manchester Business School between 2015 and 2018, examines how the CQC was working in four sectors – acute care, mental health care, general practice and adult social care – in six areas of England.

The approach was seen as a significant improvement on the system it replaced, which had been widely criticised following several high-profile failures of care.

The report, funded by the National Institute for Health Research, found that the impact of the inspection regime came about through the interactions between providers, CQC and other stakeholders not just from an individual inspection visit and report. It suggests that relationships are critical, with mutual credibility, respect and trust being very important.

Kings Fund cqc
Image source: http://www.kingsfund.org.uk

The report highlights a number of areas for improvement in CQC’s approach to regulation. It cautions that the focus on inspection and rating may have crowded out other activity which might have more impact. It recommends that CQC focus less on large, intensive but infrequent inspections and more on regular, less formal contact with providers, helping to drive improvement before, during and after inspections.

Full report: Impact of the Care Quality Commission on provider performance: room for improvement? | The Kings Fund

See also:

CQC calls for new national guidance to improve sexual safety on mental health wards

Care Quality Commission | September 2018 | Sexual safety on mental health wards

The Care Quality Commission (CQC) report -Sexual Safety on Mental Health Wards report- shares  findings and recommendations after reviewing incidents related to sexual safety on mental health wards. 

Their analysis of almost 60,000 reports found 1,120 sexual incidents involving patients, staff, visitors and others described in 919 reports – some of which included multiple incidents. More than a third of the incidents (457) could be categorised as sexual assault or sexual harassment of patients or staff.

Safety
Image source: cqc.org.uk

 

Providers and people who use services told CQC:

  1. People who use services do not always feel that they are kept safe from unwanted sexual behaviour
  2. Clinical leaders of mental health services do not always know what is good practice in promoting the sexual safety of people using the service and of their staff
  3. Many staff do not have the skills to promote sexual safety or to respond appropriately to incidents
  4. The ward environment does not always promote the sexual safety of people using the service
  5. Staff may under-report incidents and reports may not reflect the true impact on the person who is affected
  6. Joint-working with other agencies such as the police does not always work well in
  7. practice (Source: CQC)

Read the press release in full from CQC 

The report is available as a summary, easy to read format or in full from CQC

Of interest:

The BMJ  CQC: Trusts must do more to protect mental health patients from sexual abuse

Nursing Times CQC warning on sexual incidents in mental health settings

In the media:

The Guardian NHS care regulator says sexual incidents ‘commonplace’ in mental health units

Quality improvement in hospital trusts: Sharing learning from trusts on a journey of QI

Care Quality Commission | September 2018 | Quality improvement in hospital trusts: Sharing learning from trusts on a journey of QI

A new report from CQC shares what hospital trusts told CQC about their experiences of adopting and embedding Quality Improvement (QI) across their organisation. 

 

QI
Image source: cqc.org.uk

This report includes case studies to inspire those who may be considering adopting a QI approach.

Full details from CQC

The report can be downloaded from CQC