1. Jane Beach PO Regulation June 2013

2.  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

3.  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

4.  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

5.  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

6.  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

7.  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

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

9.  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.

10.  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

11.  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

12.  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

13.  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