42 Monitor and 15-16 To understand range of issues All serious incidents are reported to the CCGs scrutinise service services, all and risks via routine reporting by providers. Each incident is subject to user safety CCGs Opportunities for appropriate completion of a root analysis report which issues and scrutiny and confirm and is required to be submitted to the CCG for safeguarding by challenge review within 60 working days as stated within analysing and NHS England’s National Serious Incident Framework. Each report is reviewed by the responding to individual serious CCG’s Quality Governance Team and relevant incidents, commissioners who ensure that lessons learnt ensuring and recommendations are adequate for appropriate closure. If further assurance/challenge is practice and required this is requested. lessons are learned across organisations whom services are commissioned from To request and 15-16 All CCGs To understand local issues, As part of contractual requirements 43 receive regular Working with: pressures and risks learning from serious incidents is all providers To put appropriate in place included within the 6 monthly lessons reports from commissioned to improve service user safety learned reports for NHFT. services that NHT produce a specific Suicide and evidence trends Self Harm report for Contract meetings and highlight that identified themes and trends. issues and risks Primary Care do not currently produce and take action reports identifying themes and trends as appropriate however a quarterly serious incident report is submitted to the CCG’s Quality Improvement Committee highlights the number and type of serious incidents and any lessons learnt/changes to practice that have been identified.
42 Monitor and scrutinise service user safety issues and safeguarding by analysing and responding to individual serious incidents, ensuring appropriate practice and lessons are learned across organisations whom services are commissioned from 15-16 services, all CCGs To understand range of issues and risks via routine reporting Opportunities for appropriate scrutiny and confirm and challenge All serious incidents are reported to the CCGs by providers. Each incident is subject to completion of a root analysis report which is required to be submitted to the CCG for review within 60 working days as stated within NHS England’s National Serious Incident Framework. Each report is reviewed by the CCG’s Quality Governance Team and relevant commissioners who ensure that lessons learnt and recommendations are adequate for closure. If further assurance/challenge is required this is requested. 43 To request and receive regular reports from commissioned services that evidence trends and highlight issues and risks and take action as appropriate 15-16 All CCGs Working with: all providers To understand local issues, pressures and risks To put appropriate in place to improve service user safety As part of contractual requirements learning from serious incidents is included within the 6 monthly lessons learned reports for NHFT. NHT produce a specific Suicide and Self Harm report for Contract meetings that identified themes and trends. Primary Care do not currently produce reports identifying themes and trends however a quarterly serious incident report is submitted to the CCG’s Quality Improvement Committee highlights the number and type of serious incidents and any lessons learnt/changes to practice that have been identified.
Nottinghamshire-CC-Action-Plan-October-15-Update.docx