Monthly column for providers and professionals working in adult social care from Andrea Sutcliffe CBE, Chief Inspector of Adult Social Care.
Keeping people who use services safe from harm is a basic expectation, so this month I’m pleased to share with you a new series of resources, Learning from safety incidents.
Since April 2015, CQC has had the power to bring criminal prosecutions against health and social care providers for failing to provide care and treatment in a safe way; since then we have prosecuted nine providers relating to serious incidents. Through these prosecutions we have begun to see a number of patterns emerging and we want to highlight these to providers to help prevent similar situations from happening again in the future.
When shocking incidents occur, the people and families affected will often say they do not want anyone else to have the same experience. For this to happen, we need to understand the risks and what can be done to avoid them. This is what the Learning from safety incidents resources will do by describing a critical issue — what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.
All providers should have systems in place to protect people using their services from harm. By highlighting the key themes emerging from our enforcement activity we want to support what providers are already doing. Each resource will go into detail about a specific issue, but there are four main themes:
1. Problems with the quality and use of risk assessments
One care home had no proper system for assessing the risk to the health and safety of the people living there. Sadly, this meant the provider failed prevent a person with visual impairments from repeatedly falling in their bedroom. This should never have been overlooked.
2. Issues with documentation
We’ve found evidence of wide-ranging documentation failures including medication dosages and strengths, allergy information, and medication administration times not being accurately recorded, as well as poor systems of stock managements leading to services running out of essential medicines. Effective documentation is not about ticking boxes, it is essential for good care so that staff know what is expected of them and are capable of delivering it.
3. Issues with equipment
One service failed to have adequate radiator covers in place, which led to a terrible case where a person living with dementia suffered burns after falling onto it. This one really upset me as I remembered a similar situation I dealt with nearly 25 years ago and I could not believe we could still be making the same mistakes and causing people such harm.
4. Staff training
We saw a case where a person fell out of a shower commode chair because staff supporting them had not been informed about safety procedures and a related national safety alert. This could have been avoided if the provider had ensured staff were adequately trained.
None of these incidents should have happened and we cannot undo the impact they had on the people affected and their families, but we can learn from them and act to make sure they do not happen again. I hope you will be able to use Learning from safety incidents in your service, share with your staff, and take steps to protect the people you support.
With safety being the theme of this month’s column, I’d like to finish by highlighting the Heatwave Plan for England. The hot weather looks like it’s here to stay; although many of us will be rejoicing that summer is finally here, people using adult social care services may be more vulnerable to the heat and the impact of dehydration. The plan includes advice for health and social care staff to help keep people safe while enjoying the heatwave.
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