Version: V5
Ratified By: Quality & Safety Committee
Date ratified: 23/01/2020
Job Title of Author: Safeguarding Adult Lead and Head of Quality and Safety
Reviewed by Sub Group or Expert Group: Strategic Safeguarding Group
Equality Impact Assessed by: Safeguarding Adult Lead and Head of Quality and Safety
Related Procedural Documents: QSPOL11 NICE Implementing Best Practice Policy
Review Date: 23/01/2023
• It is the responsibility of users to ensure that you are using the most up to date document by accessing the copy available on MyCompliance
• In developing/reviewing this policy Provide has had regard to the principles of the NHS Constitution
Version Control Sheet
Version Date
Author Status Comment
V1 Nov 2011 Amy Hoye Approved
V2 Jan 2014 Updated document with Provide logo and changed wording from CECS to Provide.
V3 Nov 2015 Head of Safeguarding and Quality and Safety Facilitator Approved
V4 Nov 2017 Head of Quality and Safety Approved
V5 January 2020 Safeguarding Adult Lead and Head of Quality and Safety Updated
1. Introduction
As of 1st September 2011, the Healthcare Quality Improvement Partnership (HQIP) is responsible for the management and commissioning of the Clinical Outcome Review Programmes, previously the responsibility of the National Patient Safety Agency (NPSA). These programmes are also known as Confidential Enquiries and Inquiries.
National Confidential Enquiries (NCE’s) and Inquiries are designed to help assess quality of healthcare and stimulate improvement in safety and effectiveness by systematically enabling clinicians, managers and policy makers to learn from adverse events and other relevant data. These enquiries are integral to a standards-based system and have a key role in supporting local, continuous improvements to service quality.
Provide is committed to the timely implementation of the recommendations contained within the reports of the National Confidential Enquiries. In addition, Provide is committed to implementing best practice as defined in other high-level reports or enquires, such as the ‘Bristol Inquiry’, ‘Francis Inquiry’ etc. that make recommendations for patient safety and that these are considered in the context of the clinical services provided by the Organisation.
2. Purpose
The purpose of this policy is to outline the arrangements for Provide to take an active part in Local and National Confidential Enquiries when required and to implement recommendations following the publication of National Confidential Enquiry Reports. This could include:
• The effective dissemination of National Confidential Enquiry Reports across the organisation, therefore raising awareness of all Confidential Enquiries
• A coordinated approach to implementation
• Areas of non-compliance are identified, prioritised and acted upon by Provide
• There are audit/monitoring arrangements in place
This policy outlines the management process to be applied to all recommendations from National Confidential Enquiries within Provide.
This policy applies to all recommendations made in the reports of the National Confidential Enquiries and other high level reports and inquiries but does not replace the personal responsibilities of staff with regard to issues of professional accountability for governance or the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient in consultation with that patient and/or their relative, guardian or carer.
3. Definitions
The Healthcare Quality Improvement Partnership (HQIP) is responsible for the management and commissioning of the Clinical Outcome Review Programs, previously the responsibility of the National Patient Safety Agency (NPSA). These Programs are also known as Confidential Enquiries.
National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
The purpose of NCEPOD is to assist in maintaining and improving standards of medical and surgical care for the benefit of the public by: reviewing the management of patients; undertaking confidential surveys and research; by maintaining and improving the quality of patient care; and by publishing and generally making available the results of such activities.
Child Health Clinical Outcome Review Programme (CH-CORP)
These are commissioned by the Healthcare Quality Improvement Partnership (HQIP) and are currently being delivered by NCEPOD in collaboration with The University of Cardiff. These were previously delivered by the Royal College of Paediatrics and Child Health to systematically examine mortality and morbidity in children and young people.
Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP)
This was previously known as the Maternal and Newborn programme. A series of reports were completed by CMACE for the former Maternal and Newborn programme in three areas: Child Death Review, Maternal Deaths and Perinatal Mortality. The aim is to improve the health of mothers, babies and children by carrying out confidential enquiries on a nationwide basis and by widely disseminating findings and recommendations The Maternal, Newborn and Infant Clinical Outcome Review programme, delivered by Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACEUK) is commissioned by HQIP. The programme includes surveillance and confidential enquiries into maternal deaths and serious morbidity, as well as surveillance and confidential enquiries into stillbirths, infant deaths and serious infant morbidity,
National Confidential Enquiry into Suicides and Homicides (NCISH)
NCISH examines suicide, and homicide committed by people who had been in contact with secondary and specialist mental health services in the previous 12 months. It also examines the deaths of psychiatric inpatients which were sudden and unexplained. Previous findings of the Inquiry have informed national mental health strategies, and continue to provide definitive figures for suicide and homicide related to mental health services in the UK.
Learning Disabilities Mortality Review Programme (LeDeR)
The aim of this programme is to drive improvement in the quality of health and social care service delivery for people with learning disabilities (LD) and to help reduce premature mortality and health inequalities in this population, through national and local mortality case review. These reviews will support health and social care professionals, and policy makers, to: clarify the contribution of various causes of death to the overall burden of excess premature mortality for people with learning disabilities, identify variation and best practice and assess the impact of service change leading to the identification of key recommendations for improvement.
Independent Inquiry into Child Sexual Abuse (IICSA)
The Independent Inquiry into Child Sexual Abuse was set up in the wake of some serious high profile instances of non-recent child sexual abuse and because the government had some very grave concerns that some organisations were failing and were continuing to fail to protect children from sexual abuse.
The remit is wide ranging, but as a statutory inquiry they have unique authority to compel both witnesses and any material they feel is necessary in order to investigate where institutions have let children down in the past. The findings they make and the evidence gathered will inform the recommendations to help better protect children in the future.
High level reports or inquiries
High level reports or inquiries are less easy to define, and will largely be established in connection with high profile cases such as the Alder Hey Tissue Retention inquiry, the Laming inquiry (following the death of Victoria Climbie) the inquiry into the care provided by Mid Staffordshire NHS Foundation Trust (Francis Inquiry), which result in national recommendations for standards of performance
4. Duties
The Executive Clinical & Operations Director has overall responsibility for the implementation of national confidential enquiries and high level enquiry recommendations. Compliance against enquiry recommendations will be monitored ultimately by the Quality and Safety Committee.
The following section sets out the duties and responsibilities of particular posts and staff in relation to National Confidential Enquiries.
Chief Executive
The Chief Executive of Provide is ultimately responsible for ensuring that Provide has systems to review, assess and gap analyse recommendations and appropriately respond and learn with respect to all confidential enquiries.
Provide Board
The Provide Board is responsible for remaining abreast of National Confidential Enquiries, in order to satisfy itself that processes are robust, actions have been identified and implemented as appropriate and that learning has been identified and shared appropriately. This process of review will act as the assurance for the Provide Group Board. The Board will receive exception reports detailing National Confidential Enquiries.
Executive Clinical & Operations Director
The Executive Clinical & Operations Director is responsible for ensuring that all National Confidential Enquiries are reviewed and implemented as appropriate, via the Quality and Safety Committee.
Quality & Safety Committee
The Quality and Safety Committee is responsible for the timely review of National Confidential Enquiries. To identify the organisational lead, individual / committee within the
Provide Group, to be satisfied that a gap analysis (Appendix 2) is undertaken, actions have been identified and implemented as appropriate and that learning has been identified and shared. Where it is not possible to implement a recommendation, the Quality & Safety Committee must receive a risk assessment against the given point. This process will act as the assurance for the committee and will also form part of the assurance to Provide Group Board.
In the event of any safeguarding concerns identified by any risk assessment or Gap Analysis, Immediate action must be taken to safeguard every service user. Provide safeguarding policy and local authorities safeguarding policies and procedures must be followed appropriately.
Sub Committee
It may be appropriate for an enquiry to be handled within a sub-committee of the Quality & Safety Committee. It is the responsibility of the appointed sub-committee to undertake the gap analysis and ensure that the action plan is produced, implemented and available for monitoring at the Quality & Safety.
Assistant Directors and Service Managers
Assistant Directors and Service Managers are responsible for ensuring that any required recommendations and actions are implemented within their area(s) of control and appropriately reported.
All Staff
All staff are responsible for supplying any requested information to support implementation of this policy, in a timely and appropriate manner. An individual appointed to lead an enquiry is responsible for undertaking a gap analysis and producing an action plan to deliver against the recommendations.
Where it is not possible to implement a recommendation, a risk assessment against the given point must be undertaken.
All Staff requested to supply information to participate in conducting a confidential enquiry are required to make the Quality & Safety Committee aware of the request. The Quality & Safety team and Head of Service will support the allocated staff member to complete any internal data collection and submission. The Quality & Safety Committee must review any internal data prior to submitting this externally.
Process for Identification, Dissemination and Implementation
Once any national / local confidential enquiry recommendations are received by Provide, the request should be forwarded to the Quality & Safety team to co-ordinate dissemination of recommendations and also to monitor implementation of any changes.
The clinical and managerial leads for services are responsible for ensuring compliance with national confidential enquiry recommendations are reviewed and that any actions required are identified and action taken accordingly.
Where the organisation considers that a recommendation is relevant but for legitimate reasons could not be implemented within Provide, this will be documented on the risk register and reported to the Quality & Safety Committee, which reports to the Board.
5. Gap Analysis
A gap analysis is an essential stage in instigating the review and implementation of best practice. It is common to the implementation of national confidential enquiries. The appointed lead will develop a gap analysis for the Quality and Safety Committee, and use it to form an action plan to support final implementation.
The gap analysis will identify and assess the level of risk, and via the Board Report and when applicable, the Risk Register clearly inform the Board and organisational stakeholders regarding the priority and resources required to undertake outstanding work.
6. Monitoring, Implementation and Dissemination
The Quality & Safety Committee will receive baseline assessments from the relevant sub committees or services, as appropriate, as to Provides position in relation to National Confidential Enquiry reports and recommendations relevant to the organisation.
Where a gap analysis identifies a deficit within Provide Group, the Quality & Safety Committee will require action plans to be developed by the sub-committee or service lead as appropriate to correct these. The Quality & Safety Committee will receive summary reports regularly detailing progress towards implementation of the developed action plans.
It will be the responsibility of the relevant Assistant Directors/Heads of Service to ensure that details of any National Confidential Enquiry reports, where gaps may exist, any recommendations made and progress against these are disseminated to their teams. Provide staff will need to understand their role in ensuring they implement any required recommendations and the consequences to maintaining quality patient safety measures if not monitored. Where a report affects multiple services Organisational briefings may be implemented and staff training requirements reviewed.
To ensure that lessons learnt are embedded in clinical service delivery and that quality assurance is maintained the Quality & Safety team will monitor through the Organisational clinical audit programme as recommended by HQIP.
Provide will ensure participation at all levels in relevant confidential enquiries and performance against these will be monitored and published via the annual Quality Account.
Appendix 1: National Confidential Enquiries Process
Guidance Issued
Executive Clinical & Operations Director/Quality & Safety Committee receive and review
Distributed via Quality & Safety Committee
Quality & Safety Committee decide onward cascade and assign responsibilities
Relevant sub-groups – e.g. Learning & Development/Health & Safety/Medicines Governance & Safety – for review
Gap Analysis & Action Plan
