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Problems related to the care home and the company were known well before the Panorama expose in 2016. When the Panorama programme was aired it resulted in immediate closure of one home and all the homes which were operated by Morleigh being transferred to new operators. The Review includes reports of abuse against residents; residents being left to lie in wet urine-soaked bedsheets; concerns from relatives about their loved ones being neglected; reports of there being insufficient food for residents, no hot water and no heating; claims that dozens of residents were sharing one bathroom. Here's a summary of the report's findings: More than 100 residents had concerns raised more than once. More than 200 safeguarding alerts were made for individuals but only 16 went through to an individual adult safeguarding conference. More than 80 whistleblower or similar reports were made concerning issues that put residents at risk. 44 inspections were undertaken at Morleigh Group homes in the three-year period, the vast majority identifying breaches. There was a period of at least 12 months when four of the homes had no registered manager in place. During the three-year period reviewed the police received 130 reports relating to the care homes. A spokesperson for Cornwall Council said: “We have different procedures and policies in place and have invested time, money and staffing into making sure that we can respond better when concerns are raised.'' “One of the problems was that all the partners had their own policies and procedures but they weren’t integrated. That is probably one of the key issues that we have now addressed.” “The assessment is so different now and the organisations are working much more closely that it reduces the risk dramatically.'' This is an important and long-awaited review. This situation echoes other care home scandals across the UK. I urge everyone to read the full report and reflect on the real root causes of the problem, which I believe go well beyond failings in inter-agency policies and communication. What would your action plan be? How would you monitor it?

On 1 October 2020, the Health and Social Care Select Committee published its inquiry report into ‘Delivering core NHS and care services during the pandemic and beyond’.[1] [2] Patient Safety Learning contributed to this inquiry earlier in the year with two formal submissions of evidence. The first focused on hospital discharge arrangements, in a joint submission with CECOPS.[3] In the second we looked at the impact of COVID-19 on patient safety, specifically considering non-COVIDcare and treatment.[4] For the latter, our insights on this were partly informed by a webinar we held with patients, healthcare professionals and patient safety experts.[5] We welcome the publication of today’s report, which sets out recommendations in five different areas where action is needed to ensure the safe and effective provision of health and social care services both during and after the pandemic. Communication with patients The report recognises the importance of clear communications with patients during the pandemic. It acknowledges that there have been shortcomings in this area, stating that: “… the patient experience for some has been unacceptably poor, leaving them feeling like they have been left in 'limbo' or 'in the lurch'. Unnecessary anxiety and stress has been caused to those patients due to poor communication not just from their local hospital about the scheduling of appointments or access to treatments, but from national bodies, and on key items of guidance such as on shielding.” The Committee calls on the NHS to review the guidance they provide to trusts on how to communicate with patients about treatment changes and medical guidance in the event of a further spike in COVID-19 cases. We agree with this recommendation and reflected concerns about this issue in our submission to the inquiry. We also believe the NHS needs to consider how it communicates with patients who are impacted by the pandemic backlog of treatment and care. There needs to be honest and transparent conversations with patients about how this may affect their personal circumstances. Managing the backlog of care and treatment Recognising the serious challenge that the NHS now faces in managing waiting times and a backlog of appointments resulting from the pandemic, the report considers this in more detail in the areas of elective surgery, mental health, cancer and dental services. This was also an area of focus in our submission to the inquiry, where we highlighted other areas of concern such as chronic disease management and postnatal support.[4] We have also subsequently looked in more detail at the backlog in elective surgery and the patient safety implications of this.[6] We welcome the Committee’s recommendations that the Department of Health and Social Care and NHS should set out plans to address the backlog, along with steps that will be taken in future to manage the overall level of demand across health services. Patient Safety Learning believes that a strategy is needed to tackle the demand on NHS services in a systemic way; a published strategy that will help to ensure that decisions regarding the priority of cases are made transparently and with patient safety at the forefront. Staff access to Personal Protective Equipment (PPE) and routine testing Another area of focus in the report is the protection of staff from infection during the pandemic. The Committee asks for assurances about future supplies of PPE and presses for routine staff testing of staff in health and social care. We completely agree on the importance of this issue and in our recent work for World Patient Safety Day made the case for staff safety being intrinsically linked with patient safety.[7] In terms of physical safety during the pandemic, the case for this is clear – ensuring sufficient suitable PPE is available and that staff have access to testing is essential in both limiting the risk of passing on infection to patients as well as protecting staff themselves. We also note that in discussing PPE requirements the report refers to a specific issue around problems with fitting PPE, particularly for staff from some ethnic groups. We note the Royal College of Nursing has called for equality impact assessments on PPE and fit testing and we think that this should form part of the Department of Health and Social Care response to this report. Burnout and staff wellbeing The report notes the significant impact that the pandemic has had on both the mental and physical wellbeing of staff, advising that the Committee also has launched a separate inquiry on this, 'Workforce burnout and resilience in the NHS and social care'. This is also an area we highlighted in our submission to the inquiry and we have been sharing and highlighting staff perspectives on this during the pandemic on the hub.[8] We are also using the hub to share and publicise tools to help support staff through this period, such as a set of wellbeing resources from the Scottish Patient Safety Programme. We welcome the report’s call on NHS to set out in more detail the steps it will take “to support the mental and physical wellbeing of all staff and a plan to deal with the specific issue of sustained workplace pressure due to the current pandemic and backlog associated with the coronavirus”. Learning lessons from the pandemic The final section of the report considers the fundamental changes that have been ushered into health and social care services by the pandemic, looking in more detail at the 111 dial service, technology and digital innovations, and the independent sector. It calls on the Department of Health and Social Care and the NHS to assess the effectiveness of such changes while also noting the need to “ensure patients’ wellbeing is not jeopardised by the risk of being digitally excluded from accessing medical treatment and advice”. Patient Safety Learning welcomes these recommendations. As we noted in our response to the inquiry, the pandemic has created the opportunity for innovations in health and social care that we should seize upon to improve future services. We also believe that this presents an opportunity to design new models of care and delivery with patient safety and staff safety at their core. References Health and Social Care Select Committee, Delivering core NHS and care services during the pandemic and beyond, 1 October 2020. UK Parliament, Delivering Core NHS and Care Services during the Pandemic and Beyond, Last Accessed 30 September 2020. Patient Safety Learning and CECOPS, Hospital Discharge Arrangements, 7 May 2020. Patient Safety Learning, Response to the Health and Social Care Select Committee Inquiry: Delivering Core NHS and Care Services during the Pandemic and Beyond, 8 May 2020. Patient Safety Learning, Your voice matters: how it is shaping out work in non Covid-19 care and patient and staff safety, 14 May 2020. Patient Safety Learning, The return of elective surgery and implications for patient safety, 15 June 2020. Patient Safety Learning, Why is staff safety a patient safety issue?, 3 September 2020. Claire Cox, “I know this is burnout. I didn’t want it to be. But it is.”, Patient Safety Learning’s the hub, 11 June 2020.

Both the 2019/20 CCG and PSS CQUIN schemes comprise indicators, aligned to four key areas, in support of the NHS Long Term Plan. Patient safety Mental health Prevention of ill health Best practice pathways This document sets out the: Overview of quality and safety indicators CCG Scheme Specialised Services Scheme Scheme Eligibility and Value Rules and Guidance - Agreeing and Implementing a CQUIN Scheme

This report builds on those of previous years to provide analysis of longer-term trends and insights into the changing NHS staff profile. It focuses specifically on the critical NHS workforce issues that have been repeatedly identified in recent years: nursing shortages, and shortages of staff in general practice and primary care. The report also explores key pressure points: student nurses the international context and international recruitment retention. The report concludes by summarising the key workforce challenges that will need to be considered in the development of the full NHS people plan. Patient Safety Learning's repsonse to the report: This report on NHS workforce trends released by the Health Foundation today includes some really interesting findings, particularly around the changes in the skills mix between nurses and clinical support staff (including health care assistants and nursing assistants). The report states that in 2009/10 there were equal numbers of nurses and support staff, with one clinical support staff member for every FTE nurse in the NHS. In 2018/19, the number of support staff per FTE nurse had risen 10% to 1.1 FTE per nurse. Looking at the numbers, this translated to the NHS employing 6,500 more clinical support staff to doctors, nurses, and midwives, compared to 4,500 more FTE nurses. While changes to ratio of nurses to clinical support staff may reflect changing patient needs, technological advances and other factors, the report also notes concerns that these may be ‘introduced in an unplanned way in response to negative factors – such as cost pressures or recruitment difficulties – rather than positive drivers of improvement’. At Patient Safety Learning we believe to achieve a patient-safe future, patient safety must be more than a priority for an organisation. It must be core to its purpose, reflected in everything that it does. This should apply to the NHS when considering changes in workforce staffing and numbers so that the impact that these may have on patient safety is considered as an intrinsic part of the decision making process. While the report notes that in many cases decisions on skill mix changes are implemented well and evidence led, it’s not clear whether patient safety has been taken into account. Our view is that these decisions should involve a explicit, evidence-based assessment of the impact on patient safety which leads to the selection of the option that offers that safest outcome for patients.

Three NHS case studies (from acute care, primary care and commissioning) are described and reviewed in the light of evidence from successful organisational change in the US. Eight key features of successful leadership for patient and family centred care are outlined: Strong, committed senior leadership Active engagement of patients and families Clarity of goals Focus on the workforce Building staff capacity Adequate resourcing of care delivery redesign Performance measurement and feedback