Lessons learned, and improvements made
The service learned and made improvements when things went wrong.
- There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
- There were adequate systems for reviewing and investigating when things went wrong. The service learned, and shared lessons identified themes and took action to improve safety in the service. The service spoke to us about an incident where a service user leaving the building during winter tripped on the outside step. Service staff based on reception went to assist the service user was not hurt. As a result of this incident, additional lighting was placed outside the building to highlight the step and if a member of staff saw older service user approaching the building they would go outside and assist the service user into the building.
- The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents
When there were unexpected or unintended safety incidents:
- The service gave affected people reasonable support, truthful information and a verbal and written apology
- They kept written records of verbal interactions as well as written correspondence.
- The service told us that it acted on and learned from external safety events as well as patient and medicine safety alerts. However, the service did not have in place a process for receiving and disseminating safety alerts to relevant personnel within the service. We asked how the service assured itself that care was being provided in line with current safety alerts advice and was told that several clinical staff were able to access the alerts through external sources.