Service User Safety Incident Response Plan

The PSIRF supports the development of a PSIR system that prioritises compassionate engagement and involvement of those affected by safety incidents. ‘Those affected’ include staff and families in the broadest sense; that is – the person or Service User to whom the incident occurred, their family and close relations. Family and close relations may include parents, partners, siblings, children, guardians, carers, and others who have a direct and close relationship with the individual to whom the incident occurred. 

Engagement with those affected and their involvement in PSIs take account of individual needs. We consider this in both the design and delivery of their service. For example: 

• Wherever possible service users/Service User safety partners should be involved in co-producing the design, delivery and review of the processes 
• The diversity of Service User’s safety partners involved in any planning should be considered to ensure they reflect the population the organisation serves 
• Language services should be easily accessible by engagement leads. 
• The affected person is best placed to advise on what their needs are, and they should be acted on where appropriate 
• Working with those affected by the PSI to understand and answer any questions about the incident and signpost them to support as required.

Overarching Aims	Specific Objectives
1. Improve the safety of the care we provide to our service users.	•       Develop a climate that supports a just culture and an effective learning response to service user safety incidents. •       Respond to service user safety incidents purely from a service user safety perspective •       Better measurement of improvement initiatives based on learning from incident response
2. Improve the experience for patients, their families and carers wherever a patient safety incident or the need for a PSII is identified	•       Act on feedback from service users, families,carers and staff about their concerns with service user safety incident responses. •       Support and involve service users, families and carers in incident response, for better understanding of the issues and contributory factors to Promote a Duty of Candour
3. Improve the working environment for staff in relation to their experiences of patient safety incidents and investigations	•      Act on feedback from staff about their concerns with service user safety incident responses. •       Support and involve staff in service user safety incident response, for a better understanding of the issues and contributory factors

 

Application of a range of system based approaches to learning from patient safety incidents.

We use the national system-based learning response tools and guides, or system- based equivalents, to explore the contributory factors to a PSI or cluster of incidents, and to inform improvement.

Those leading the PSIR and those involved in the oversight of learning and improvement emerging from PSIR have the required knowledge and experience to support this approach.

The tools available help us to respond to PSI’s prompt consideration of inequalities, including when developing safety actions.

Using the tools in the framework ensures that we engage and involve Service Users, families and staff following a PSI considering their different needs.

The NHS Long Term Plan emphasises the approach that is needed to address the longstanding health inequalities and inequities that have led to poorer outcomes, harm and premature deaths. Through the implementation of our Service User safety incident response policy and plan, PrimaryCarers 247 will help address the national priorities.

Some Service Users are less safe than others in a healthcare setting. The PSIRF provides a mechanism to directly address these unfair and avoidable differences in risk of harm from healthcare:

• The PSIRF’s more flexible approach makes it easier to address concerns specific to health inequalities. It provides the opportunity to learn from Service User safety incidents regardless of severity.

• The PSIRF prompts consideration of inequalities during the learning response process including when developing safety actions.
• Engaging and involving Service Users, families and staff following a Service User safety incident will take into consideration individual needs to ensure the process is inclusive and effective.
• The framework endorses a system-based approach (instead of a person- focused approach) and is explicit about the training and skill development required to support an approach across our
• Implementation of the Learning From Service User Safety Events service will enable a deeper understanding of health inequalities, as data on protected individual characteristics will be collected. This will assist with the development of Service User safety incident response policies and plan.

The PSIRF recognises that learning and improvement following a patient safety incident can only be achieved if supportive systems and processes are in place. It supports the development of an effective patient safety incident response system that prioritises compassionate engagement and involvement of those affected by patient safety incidents (including patients, families and staff). This involves working with those affected by patient safety incidents to understand and answer any questions they have inrelation to the incident and signpost them to support as required.

Primary Carers 247 is committed to the engagement principles outlined in the NHS England engagingand involving patients, families and staff following patient safety incident guidance. This ensures that when patient safety incidents occur:

1. Apologies are
2. Approach is
3. Timing is
4. Those affected are treated with respect and
5. Guidance and clarity are
6. Those affected are
7. Approach is collaborative and
8. Subjectivity is
9. Strive for

The four key steps of engagement (Please see graphic below) will be followed during the Service User Safety Incident Investigation process to ensure those involved/affected by patient safety incidents havean opportunity to contribute to the learning and improvement.

https://www.england.nhs.uk/wp-content/uploads/2022/08/B1465-2.-Engaging-and- involving…-v1-FINAL.pdf

Steps of engagement

Overview

The PSIRF supports organisations to respond to incidents and safety issues in a way that maximises learning and improvement, rather than basing responses on arbitrary and subjective definitions of harm. Beyond nationally set requirements, organisations can explore Service User safety incidents relevant to their context and the populations they serve rather than only those that meet a certain defined threshold.

Resources and training to support Service User safety incident response

Primary Carers 247 is fully committed to the PSIRF and ensures that all staff who undertake roles linked to Service User safety incident response have the necessary training and competencies required.

The responsibilities set under the PSIRF will form part of existing job roles within the organisation.Although the implementation and delivery of the PSIRF will be a collaborative approach from all PrimaryCarers 247 staff members. Three key roles have been identified:

1. Learning Response Leads who will lead Service User Safety Incident
2. Engagement Leads who will assist with Service User Safety Incident Investigations througheffective engagement and involvement with those
3. Investigators who will complete investigations for Service User safety incidents that meet our agreed list of Service User safety priorities.

All Primary Carers 247 staff will complete level 1 (essentials of Service User safety) and level 2 (access topractice) of the Service User Safety Syllabus as part of their mandatory training requirements. Thisensures human factors and systems thinking are embedded across the organisation and will enable a proactive approach to identifying risks to safe care. Primary Carers 247 monitors all mandatory training compliance across the organisation.Our Service User safety incident response plan.

Our plan sets out how Primary Carers 247 intends to respond to Service User safety incidents over aperiod of 12 to 18 months. The plan is not a permanent set of rules that cannot be changed. We will remain flexible and consider the specific circumstances in which each Service User safety incident occurred and the needs of those affected, as well as the plan.

Our service user incident response plan

Our plan sets out how this organisation intends to respond to Service Users/Service User’s safety incidents over a period of 12 to 18 months. The plan is not a permanent set of rules that cannot be changed. We remain flexible and consider the specific circumstances in which each safetyincident occurred, and the needs of the people affected, as well as the plan.

The plan covers:

• Identifying and agreeing on the persons safety issues most pertinent to our organisation, including stakeholder engagement and data sources
• Identifying and agreeing on our service users/Service User’s safety improvement profile which includes
• A consolidated list of all improvements and service transformation work that impacts the Service User’s safety both underway and planned
• Any learning from nationally acquired responses to inform improvements

PSI type	Required response	Anticipated improvement route
EG: death thought more likely than not due to problems in care (incident meeting the learning from deaths criteria for patient safety incident investigations (PSIIs))	Patient Safety Incident Investigation	Create local organisational actions and feed these into the quality improvement. Respond to recommendations from external referred agency or organisation
EG: incident meeting Safeguarding Criteria	Referred to LA Adult Safeguarding team re investigations	Respond to recommendations as required and feed actions into the quality improvement strategy

The type of response will depend on:

• The views of those affected, including Service Users and their families
• Capacity available to undertake a learning response
• What is known about the factors that lead to the incident(s)
• Whether improvement work is underway to address the identified contributory factors
• Whether there is evidence that improvement work is having the intended effect/benefit
• If an organisation and its senior management are satisfied risks are being appropriately managed

Reviewing our Service User safety incident response policy and plan

Our Service User safety incident response plan is a ‘living document’ that will be appropriately amendedand updated as we use it to respond to Service User safety incidents. We will review the plan every 12 to18 months to ensure our focus remains up to date; with ongoing improvement work, our Service Usersafety incident profile is likely to change. This will also provide an opportunity to re-engage with stakeholders to discuss and agree on any changes made in the previous 12 to 18 months. Updated plans will be published on our website, replacing the previous version.

A rigorous planning exercise will be undertaken every four years and more frequently if appropriate (e.g., a full review of Service User safety incident investigation reports, improvement plans, complaints, claims, staff survey results, inequalities data, reporting data and wider stakeholder engagement).