Managers

What we look for

Safe

Learning culture

  • How are you assured all incidents are reported?
  • Is the level of harm recorded reflective of the harm suffered?
  • How are equality characteristics recorded and analysed for all incidents?
  • Describe the culture of improvement and change?
    • How supportive is this process for staff?
  • Can you describe your duty of candour process?
  • How is clinical data including socio-demographic characteristics, such as ethnicity, routinely recorded, analysed and used to improve the quality of services?

Effective

Monitoring and improving outcomes

  • Are all themes, no matter the levels of harm, on the risk register to help drive improvement?
  • How are you assured actions for improvement are implemented and monitored for effectiveness?

Well-led

Governance management and sustainability

  • How are you assured that duty of candour is always carried out in accordance with regulation 20 of the Health and Social Care Act 2008?
  • Describe any changes in the service following a duty of candour review.
  • Is the compliance with the duty of candour audited?
  • Do you have independent panel members, such as external professionals, invited to assist in incidents reviews?
  • Does the service have an incident investigation procedure?
  • How are you assured incidents are investigated consistently?
  • How are themes and trends identified shared with frontline staff and reported to the board?
  • Describe the current themes and trends of harm in your service, in line with NHS England's Patient Safety Incident Response Framework (PSIRF) guidance.
  • How are you assured lower levels of harm are reviewed to drive improvement?
  • How often are serious incidents review meetings held? How are these recorded and was there appropriate monitoring of action?
  • Are all neonatal deaths reviewed by a multidisciplinary group using the Perinatal Mortality Review Tool?
  • Are all reviews documented in detail?
  • How many incidents in the last 6 months have been referred to the Maternity and Newborn Safety Investigations programme (MNSI) for investigation?
    • Do you have any examples of actions to address recommendations, and how are these monitored?
  • How are you assured actions identified through incident investigation are resolved promptly to prevent harm?