Patient Safety Incident Response Plan

Falcon-Care is an experienced domiciliary care agency who also provide nursing and staffing support to our local communities. Domiciliary care is regulated and approved as a service provider by the Care Quality Commission (CQC) in accordance with the Health and Social care act 2008 and the Care Act 2014. We respond to the individual needs of our clients on a 24-hour basis, 365 days a year.

Our client groups are diverse, ranging from individuals requiring care within the privacy of their own homes on a short and long-term basis. This can be working alongside local government organisations or within the private sector.

“Delivering excellence in care and support whilst going above and beyond to support the local communities”.

We have a strong set of values that have been developed with our clients, carers and staff, our values are embedded across the organisation. They guide our behaviours and actions, ensuring we treat each other with compassion and care, supporting us to provide the highest quality care to service users and carers.

We offer a high-quality service and are proud to have achieved an overall rating of ‘Good’ from our regulators, the Care Quality Commission (CQC).

At Falcon-Care we believe that everyone should be empowered to live their lives as they choose; this may include the right to remain living in your own home or the right to live your life in a fulfilling way that you choose. Whatever a client or clients’ needs are, we believe that by providing the right care and assistance can enable people to do so with dignity in an independent, safe and secure way.

• We believe in complete honesty and integrity in everything we set out to accomplish.
• We believe in showing absolute compassion to all our clients and colleagues.
• We highly value our nursing and care and support workers, without whom there would be no Falcon-Care.
• We believe in offering all staff the opportunity to excel and achieve.
• We believe in the strength of our policies and procedures and the importance of always adhering to them.
• We believe in consistently maintaining fair and competitive fee levels whilst maintaining an outstanding quality of service.
• We believe in continuing to identify and support opportunities for improvement.
• We believe that Falcon-Care gains additional strength from overcoming obstacles.
• We believe that our mission can only be realised by sharing our beliefs and working together as a team.

The services we offer

The service may be anything from a 30-minute welfare check to 24hr live in care and Supported Living services. Our care and support workers can provide you with the following types of care and support:

• Help with personal care and hygiene.
• Help with getting up and going to bed.
• Prompting or giving medicines and collecting or returning medication from pharmacies or dispensing GP surgeries.
• Preparing meals and helping at mealtimes.
• Paying rent or household bills.
• Collecting pensions and shopping.
• Laundry and housework.
• Support with social activities such as attending a day centre, visiting friends or family, going to your church or club etc.
• Attending medical appointments with you.

Our Specialisms/Services

Who we provide care for:

• Caring for Adults over 65 years of age.
• Caring for Adults under 65 years of age
• Caring for Children (0-18yrs)
• Physical Disabilities.
• Dementia.
• End of life/Palliative Care
• Learning Disabilities or Autistic spectrum disorder
• Supported Living
• Sensory Impairments
• Substance misuse problems
• Complex Care
• Eating Disorders
• Mental Health

A Patient Safety Incident Response Plan (PSIRP) sets out how Falcon-Care will respond to patient safety incidents reported by staff, Customers or their families as part of work to continually improve the quality and safety of the care provided.

The Registered Manager will develop the PSIRP to learn and improve through patient safety incident investigations (PSIIs). It should be based on a thorough understanding of the Customer safety incident profile of Falcon-Care, ongoing improvement priorities, available resources and the priorities of stakeholders including Customers.

The Registered manager should ensure the plan:

Demonstrates a thorough analysis of relevant organisational data

Demonstrates a collaborative stakeholder engagement process (informed by thorough service and stakeholder mapping activities to ensure all areas are involved and represented appropriately)

Is a ‘living document’ that will be appropriately amended and updated as it is used to respond to patient safety incidents

Is reviewed every 12 to 18 months to ensure the focus remains up to date; with ongoing improvement work, the patient safety incident profile is likely to change. It will also provide an opportunity to re- engage with stakeholders to discuss and agree any changes made in the previous 12 to 18 months

Provides a clear rationale for the response to each identified patient safety incident type

Is updated as required and in accordance with emerging intelligence and improvement efforts

Is published on the website of Falcon-Care

Is updated to incorporate any new learning, the changing risk profile of Falcon-Care, as well as any ongoing improvement initiatives. This will ensure that incident response becomes a key element of the approach taken by Falcon-Care to wider safety management

Patient safety incident response plan

The patient safety incident response plan of Falcon-Care must be agreed by the integrated care board (ICB), other commissioning leads where required, and the board, leadership group or Falcon-Care for sign- off.

Under the PSIRF, each organisation’s patient safety incident response plan will outline how they will respond to PSIs over a period of 12 to 18 months. The four stages of planning response methods are:

• Examine patient safety incident records and safety data
• Describe safety issues demonstrated by the data
• Identify improvement work underway
• Agree response methods

A rigorous planning exercise that includes a review of data (including PSII reports, improvement plans and reporting data) and wider stakeholder engagement should happen, at a minimum, every four years and more frequently if appropriate (as agreed with the integrated care board (ICB) of Falcon-Care) to ensure efforts continue to be balanced between learning and improvement. Four years is suggested before performing a rigorous planning exercise to allow enough time for safety actions and subsequent improvement to have effect.

Stakeholders

Falcon-Care should work with a range of stakeholders to create a list of patient safety incident types that are jointly identified as areas of interest in terms of risk and potential learning and improvement. The Registered Manager can list as many incident ‘types’ as deemed appropriate.

The stakeholders that Falcon-Care should work with should be diverse and include, but not be limited to:

• Patient safety partners and/or patient and public representative groups such as local Healthwatch Integrated Care Board (ICB) patient safety specialists
• CQC and other professional regulators
• Specific and distinct clinical governance teams, clinicians and safety champions

Patient safety incident types should be agreed with the Falcon-Care; they could include:

• Pressure ulcers, category 3 and above.
• Falls with significant injury including fracture
• Unexpected death after unrecognised physical health deterioration/lack of prompt intervention
• Medication errors
• Violence and distressed behaviour, resulting in significant injury

While planning supports proactive allocation of patient safety incident response resources, there will always need to be a reactive element in responding to incidents.

A response should always be considered for patient safety incidents that signify an unexpected level of risk and/or potential for learning and improvement but fall outside the issues or specific incidents described in the organisation’s plan.

Data

The patient safety incident response plan of Falcon-Care must be agreed by the integrated care board (ICB), other commissioning leads where required, and the board, leadership group or Falcon-Care for sign- off.

Under the PSIRF, each organisation’s patient safety incident response plan will outline how they will respond to PSIs over a period of 12 to 18 months. The four stages of planning response methods are:

• Examine patient safety incident records and safety data
• Describe safety issues demonstrated by the data
• Identify improvement work underway
• Agree response methods

A rigorous planning exercise that includes a review of data (including PSII reports, improvement plans and reporting data) and wider stakeholder engagement should happen, at a minimum, every four years and more frequently if appropriate (as agreed with the integrated care board (ICB) of Falcon-Care) to ensure efforts continue to be balanced between learning and improvement. Four years is suggested before performing a rigorous planning exercise to allow enough time for safety actions and subsequent improvement to have effect.

Falcon-Care has a continuous commitment to learning from patient safety incidents. Safety incidents would include, pressure related skin damage and deteriorating client. There was no stakeholder involvement although discussion have taken place with the board and consulted with the ICB patient safety team to fully understand the requirements of PSIRF and to understand the practicalities of planning and implementation.

Data sources:

To define our patient safety response profile, we have reviewed our incidents for any themes and trends and considered feedback from clients/patients and complaints. Where possible have considered what the data tells us about inequalities in patient safety and will support larger organisations with patient safety incident investigations and the ICB when necessary, where learning emerges, and improvement can be made.

Falcon-Care Act in response to a patient safety incident may take different forms.

Sometimes rapid action is needed to respond to imminent risk (e.g. removing broken/faulty equipment). These actions should be completed as soon as practicable and should be captured as part of a specific incident response.

Developing safety actions that respond to underlying system issues starts with identifying and understanding aspects of the work system that need to change to reduce risk and potential for harm (i.e. areas for improvement or system issues). Actions to reduce risk (i.e. safety actions) are then generated in relation to each defined area for improvement.

Key to continuous quality development at Falcon-Care:

• Agree areas for improvement. Specify where improvement is needed, without defining how this improvement is to be achieved
• Define context. Agree approach to developing safety actions by developing context
• Define safety actions to address areas for improvement. Continue to involve the team – make this a collaborative experience
• Prioritise safety actions. Avoid prioritising actions based on intuition/opinion alone
• Define safety measures. Identify what can be measured to determine whether the safety action is influencing what is intended. Prioritise safety measures. Document who is responsible for collecting, analysing, reporting and acting on the data collected
• Write safety actions. Document in a learning response report or safety improvement plan, including details of measurement and monitoring
• Monitor and review. Continue to be curious and monitor if safety actions are impactful and sustainable
• Document, record and review safety action progress and impact through governance groups and links to quality improvement

Safety improvement plans bring together findings from various responses to patient safety incidents and issues. They can take different forms, for example, Falcon-Care might consider:

• Creating an organisation-wide safety improvement plan summarising improvement work
• Creating individual safety improvement plans, each focusing on a specific service, pathway, or location
• Reviewing output from learning responses undertaken in relation to single incidents collectively, when it is felt that there is sufficient understanding of the underlying, interlinked system issues
• Creating a safety improvement plan to tackle broad areas for improvement (overarching system issues) Falcon-Care should consider which approach is best suited to the data it has, and insight gained.

The key is to demonstrate why a specific safety improvement plan approach is the right one for Falcon-Care based on available data, stakeholder views, improvement priorities, the patient safety incident profile and insight from patient safety incident responses.

There are no thresholds for when a safety improvement plan should be developed, for example, after completing a certain number of learning responses. The decision to do so must be based on knowledge gained through the learning response process and other relevant data.

Oversight Roles and Responsibilities

Falcon-Care should identify a PSIRF executive lead to support the responsibilities of the PSIRF. The lead must also provide direct leadership, advice, and support in complex/high profile cases, and liaise with external bodies as required.

The PSIRF executive lead may be the person with overarching responsibility for quality or, more specifically, Customer safety. They should be a member of the leadership team at Falcon-Care and equipped (through training and professional development) with up-to-date safety skills, knowledge and experience as described in the patient safety incident response standards.

Some patient safety incidents, such as Never Events and deaths thought more likely than not due to problems in care, will always be considered for a Patient Safety Incident investigation (PSII) to learn and improve. For other types of incidents which may affect certain groups of our clients, a PSII will also be required.

Falcon-Care should determine PSIRF priorities to focus on for the year. These should be chosen based on Customer safety insights and thematic analysis.

Falcon-Care should work with a range of stakeholders to create a list of patient safety incident types that are jointly identified as areas of interest in terms of risk and potential learning and improvement.

Levels of Harm Physical Harm:

No physical harm: No physical harm occurred.

Low physical harm: Low physical harm is when all of the following apply:

Minimal harm occurred – patient(s) required extra observation or minor treatment

Did not or is unlikely to need further healthcare beyond a single GP, community healthcare professional, emergency department or clinic visit

Did not or is unlikely to need further treatment beyond dressing changes or short courses of oral medication

Did not or is unlikely to affect that patient’s independence

Did not or is unlikely to affect the success of treatment for existing health conditions

Moderate physical harm: Moderate harm is when at least one of the following applies:

Has needed or is likely to need healthcare beyond a single GP, community healthcare professional, emergency department or clinic visit, and beyond dressing changes or short courses of medication, but less than 2 weeks additional inpatient care and/or less than 6 months of further treatment and did not need immediate lifesaving intervention

Has limited or is likely to limit the patient’s independence, but for less than 6 months

Has affected or is likely to affect the success of treatment, but without meeting the criteria for reduced life expectancy or accelerated disability described under severe harm

Severe physical harm: Severe harm is when at least one of the following applies:

Permanent harm/permanent alteration of the physiology

Needed immediate lifesaving clinical intervention

Is likely to have reduced the patient’s life expectancy

Needed or is likely to need additional inpatient care of more than 2 weeks and/or more than 6 months of further treatment

Has, or is likely to have, exacerbated or hastened permanent or long-term (greater than 6 months) disability of their existing health conditions

Has limited, or is likely to limit, the patient’s independence for 6 months or more Fatal (previously documented as ‘Death’ in NRLS):

Staff should select this option if, at the time of reporting, the patient has died and the incident may have contributed to the death, including stillbirth or pregnancy loss. Staff will have the option later to estimate to what extent it is considered that a patient safety incident contributed to the death

Psychological Harm:

No psychological harm: Being involved in any patient safety incident is not pleasant. Staff should only select ‘no harm’ if they are not aware of any specific psychological harm that meets the description of ‘low psychological harm’ or worse.

Low psychological harm: Low psychological harm is when at least one of the following applies:

Distress that did not or is unlikely to need extra treatment beyond a single GP, community healthcare professional, emergency department or clinic visit

Distress that did not or is unlikely to affect the patient’s normal activities for more than a few days

Distress that did not or is unlikely to result in a new mental health diagnosis or a significant deterioration in an existing mental health condition

Moderate psychological harm: Moderate psychological harm is when at least one of the following applies:

Distress that did or is likely to need a course of treatment that extends for less than six months

Distress that did or is likely to affect the patient’s normal activities for more than a few days but is unlikely to affect the patient’s ability to live independently for more than six months

Distress that did or is likely to result in a new mental health diagnosis, or a significant deterioration in an existing mental health condition, but where recovery is expected within six months

Severe psychological harm: Severe psychological harm is when at least one of the following applies:

Distress that did or is likely to need a course of treatment that continues for more than six months

Distress that did or is likely to affect the patient’s normal activities or ability to live independently for more than six months

Distress that did or is likely to result in a new mental health diagnosis, or a significant deterioration in an existing mental health condition, and recovery is not expected within six months