Title of Report: Duty of Candour, CQC Registration 20. Ramona Duguid, Acting Director of Governance

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1 Report to Trust Board of Directors Date of Meeting: 24 March 2015 Enclosure Number: 14 Title of Report: Duty of Candour, CQC Registration 20 Author: Executive Lead: Responsible Sub- Committee (if appropriate): Executive Summary: Ramona Duguid, Acting Director of Governance Gail Naylor, Executive Director of Nursing and Midwifery Safety & Quality Committee The overarching aim of the regulation is to ensure that providers are open and honest with patients when things go wrong with their care and treatment. This has been a requirement from the NHS Standard Contract however it is also legally enforceable as part of our Registration with the Care Quality Commission (CQC) in accordance with Regulation 20 which came into force in November The Trust has had in place arrangements to ensure compliance with this standard for over 12 months and has reviewed its current position against the requirements of the Regulation at a Trust Board development session in February This report summarises the requirements of the regulation and the key areas of improvement discussed at the Trust Board Development session. The outputs of the Board Development Session have also been discussed at the Safety and Quality Committee and Clinical Policy Group in March Appendix 1 outlines the improvement plan following the Board development session. Board Assurance Framework Reference: 4.2 Page 1 of 6

2 Risk Rating (high, medium, low risk) and any recommended changes to risk rating: Compliance, legal and national policy regulatory requirements: Financial Implications: Action required by the Board Medium Duty of Candour is a core CQC Regulatory requirement. N/A To approve: To note: For information: Discussion and decision Where the Board is made aware of key points but no decision required For reading and consideration and for discussion by exception only The Board are asked to APPROVE the plan attached at Appendix 1. Data quality: Source: Ramona Duguid, Acting Director of Governance Validated by: Ramona Duguid,, Acting Director of Governance Date: 18/03/2015 Page 2 of 6

3 TRUST BOARD MARCH 2015 OUR COMPLIANCE WITH DUTY OF CANDOUR CQC REGULATION INTRODUCTION The overarching aim of the Duty of Candour regulation is to ensure that providers are open and honest with patients when things go wrong with their care and treatment. This has been a requirement from the NHS Standard Contract however it is also legally enforceable as part of our Registration with the Care Quality Commission (CQC) in accordance with Regulation 20 which came into force in November The Trust has had in place arrangements to ensure compliance with this standard for over 12 months and has reviewed its current position against the requirements of the Regulation at a Trust Board development session in February This report summarises the requirements of the regulation and the key areas of improvement discussed at the Trust Board Development session. 2. SUMMARY OF THE REGULATION To meet the requirements of the regulation, a provider has to, aas soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred a health service body must: notify the relevant person that the incident has occurred, the notification to be given must: - be given in person by one or more representatives of the health service body - provide an account, which to the best of the health service body s knowledge is true, of all the facts the health service body knows about the incident as at the date of the notification - advise the relevant person what further enquiries into the incident the health service body believes are appropriate - include an apology, and - be recorded in a written record which is kept securely by the health service body. Provide reasonable support to the relevant person in relation to the incident, including when giving such notification. Page 3 of 6

4 The Regulation has set out guidance in relation to the actual patient safety incident description to assist with the practical application of this Regulation, the key points are summarised below: The Term notifiable safety incident means: Any unintended or unexpected incident that occurred in respect of a service user during the provision of a regulated activity that, in the reasonable opinion of a health care professional, could result in, or appears to have resulted in: the death of the service user, where the death relates directly to the incident rather than to the natural course of the service user s illness or underlying condition, or The term severe harm: severe harm means - a permanent lessening of bodily, sensory, motor, physiologic or intellectual functions, - including removal of the wrong limb or organ or brain damage, that is related directly to the incident and not related to the natural course of the service user s illness or underlying condition moderate harm or prolonged psychological harm to the service user. The term moderate harm means: Harm that requires a moderate increase in treatment: - an unplanned return to surgery - an unplanned re-admission - a prolonged episode of care - extra time in hospital or as an outpatient - cancelling of treatment - or transfer to another treatment area (such as intensive care). - significant, but not permanent, harm. prolonged psychological harm means psychological harm which a service user has experienced, or is likely to experience, for a continuous period of at least 28 days. 3. HOW ARE WE COMPLYING WITH THIS REGULATION The Trust formally records compliance with Duty of Candour for both Serious and Moderate incidents on the Ulysses management system, which is reported publicly in the Safety and Quality quarterly report. All patients and or their families receive a copy of the complete Serious Incident reports, which usually also involves a face to face meeting so that support and simple explanations can be given about what went wrong and what our investigations have confirmed. Page 4 of 6

5 However, it is recognised that further work is required in the moderate related category of harm in terms of the written communication with the patient and their family. In February 2015 a Trust Board Development session was held to review the current position and key areas for improvement. An improvement plan has been drafted and is attached at appendix 1, which has also been approved by the Safety and Quality Committee in March 2015 with some additional actions added to the plan. 3.1 Engagement with Clinical Policy Group In addition to the Board development session, the CPG debated the current position and our areas for improvement in March This focused on the moderate aspects of harm and the need to ensure that our policies provided clear guidance but also allowed for clinical judgment on a case by case basis for example known complications from a planned treatment which result in prolonged care/treatment. It was agreed that the feedback from staff on using the tools and templates as well as the engagement from staff through the training would be used to make any changes or additions to the Trust policies during 2015 so that clinical staff in particular can feedback and inform the policies and how they work in practice. 4. RECOMMENDATION The Board are asked to RATIFY the plan attached at Appendix 1. Page 5 of 6

6 APPENDIX 1 DUTY OF CANDOUR IMPROVEMENT PLAN DOMAIN ACTION REQUIRED LEAD TARGET DATE POLICY 1.1 Incident Management Policy to be updated to reference CQC regulation requirements Ramona Duguid 31/03/ Being Open Policy to be updated to clearly link to the incident management policy and include the practical tools for staff to use Ramona Duguid 31/03/ Incident Management and Being Open Policy to be classed as Priority 1. Ramona Duguid 31/03/2015 PRACTICE 1.4 Ulysses System to be Upgraded to Improve Duty of Candour Reporting Helen Kelly 17/04/2015 a) Test System uploaded to NCUH Mike Stacey 13/03/2015 b) Configuration and testing of DoC section. Mike Stacey 20/03/2015 c) Preliminary update of Reference Manual 13 th March 20 th March. Mike Stacey 20/03/2015 d) Briefing of Business Units Helen Kelly 20/03/2015 e) WebEx explaining all system updates Mike Stacey 16/03/2015 f) Update of Live & Web systems Mike Stacey 23/03/2015 g) Finalisation of Reference Manual update Mike Stacey 29/03/2015 h) Cascade of information to Business Units Helen Kelly 10/04/ Templates for written communication with patients to be developed /updated into the updated policy Ramona Duguid 31/03/2015 (1.2) with a 3 month review date. Templates to be accessible in all wards and departments. 1.6 Weekly Business Unit reports to be refined regarding DoC compliance. Helen Kelly 17/04/ Intranet page for Being Open to be added to safety and quality section for easy access to the tools Ramona Duguid 31/03/2015 and materials. PEOPLE 1.8 Mandatory Training Package for ALL staff to be live by 17 April to support the implementation of the Helen Kelly 17/04/2015 Policy. This will include the different levels of training required as set out in the policy. PATIENTS 1.7 Patient information leaflet for Duty of Candour to be finalised as part of updated Policy. Ramona Duguid 31/03/ Information on the Website to be updated for all patients and public. Rhia Whytlock 30/04/ Arrangements to receive patient feedback on how the Trust is applying the DoC to be explored. Gail Naylor 29/05/2015 GREEN DELIVERED AMBER ON TRACK Page 6 of 6