Jane BeachPO Regulation

June 2013

Summary of Reports key findings Suggested causes of care failings

◦ Why they were allowed to continue Key recommendations

◦ Implications for community practitioners◦ Focus on areas of practice◦ Culture change◦ Duty of care

Appalling standards of care

Hundreds of patients died unnecessarily

System failings at every level of the NHS

Failure to recognise and react to numerous warning signs

A focus on business, not patients Lack of leadership and leadership skills Tolerance of poor standards Closed, bullying culture Disengagement from management Low staff morale Isolation Lack of candour Reliance on external assessments Denial

Why they continued Persistence in continuing with services

known to be deficient; Absence of effective risk assessment or

transitional arrangements for significant organisational changes;

Priority given to confidentiality and support of colleagues and organisations over the duty to warn others of safety risks.

NHS culture

Accountability for implementation Putting the patient first Fundamental standards of

behaviour/standards A common culture Responsibility for, and effectiveness of

standards Effective regulation/governance Effective complaints handling

Commissioning for standards Performance management and scrutiny Medical education and training Openness, transparency and candour Focus on nursing Leadership at all levels Regulation of fitness to practise Caring for the elderly Information systems

Record keeping inconsistent, incomplete, separation of notes and failure to notice early warning signs◦ Accountability◦ Continuity of care◦ Relationships◦ Patient safety◦ Duty of care

Acceptance of poor standards◦ You must disclose information if you believe

someone may be at risk of harm…◦ You must act without delay if you believe that

you, a colleague or anyone else may be putting someone at risk.

◦ You must inform someone in authority if you experience problems that prevent you working within this code or other nationally agreed standards.

Shortfall in nursing posts and inappropriate skill mix◦ Collate evidence◦ Check this against local and national policies◦ Discuss with colleagues◦ Risk/health and safety assessments◦ Raise concerns, ensuring they are recorded◦ Resolve where possible◦ Support from union rep

The best healthcare organisations and staff should welcome and embrace change which results in better services for patients, but generally this should be evolutionary and risk-based.◦ Professional responsibility to update practice◦ Change should be evidenced based◦ Comprehensive impact and risk assessments◦ Effective consultation◦ Client first◦ Outcome focussed◦ Accountability at all levels

Need to reassert professionalism◦ Be angry and act◦ Zero tolerance of substandard care

Staff need to feel safe to raise concerns◦ Positive safety culture◦ Responding to concerns should be part of the

solution Duty of candour

◦ Be honest about what can/cannot be done Criminality

◦ Raise and escalate concerns

NHS Constitution (March 2012)◦ You have a duty to accept professional accountability and

maintain the standards of professional practice as set by the appropriate regulatory body applicable to your profession or role.

Employer, manager, HCP all have a duty to ensure that what is done is done safely and appropriately

Stating that you were ‘instructed’ to work unsafely or that everyone else was, is no defence

Loss of registration prevents you practising anywhere not just with employer