Safety Starts with Me is about everyone's responsibility to learn from safety incidents and improve the safety of First Community for everyone that works here or uses our services.
Safety Starts with Me aligns with the National Patient Safety Strategy recognising the importance of improving safety across the whole system and giving everyone the skills and opportunity to improve patient safety.
It is with great pleasure I introduce First Community's Patient Safety Incident Response Plan for the period 1 April 2026 to 31 March 2027. I am immensely proud to reflect on the commitment, professionalism and compassion demonstrated across all our services that means we have been able to review our plan annually making this the fourth plan . This year, our collective focus on learning and improvement has remained strong. Through our weekly safety huddle, we have reviewed more than 100 incidents, each one an opportunity to deepen our understanding of how care is delivered in real time and learning to continuously strengthen patient safety. The growth of First Community's safety huddle, both in contribution and engagement, shows how embedded learning, openness and psychological safety have become within First Community.
A significant achievement this year has been the successful closing of three of our patient safety priorities: safer administration of insulin, administration of PRN controlled drugs on Caterham Dene Ward, and falls on Caterham Dene Ward. These areas required sustained effort, multidisciplinary involvement and a relentless commitment to reducing risk and improving outcomes. I want to thank every team member and our patients who have contributed insights, actions and reflections.
As we look ahead, our focus will remain firmly on our learning culture, one where colleagues are supported to speak up, where insights are valued, and where improvement is driven by real world experience and compassion for both patients and staff. We will continue to use our safety huddle as a dynamic space to identify emerging themes, respond to risks, and celebrate positive practice. Together, we will ensure our learning responses remain timely, proportionate and grounded in the principles of the Patient Safety Incident Response Framework.
I am grateful to each of you for your continued dedication to patient safety and your commitment to supporting each other. I look forward to another year of learning, collaboration and improvement as we continue to deliver First Rate Care by First Rate People.
Improvement and learning from patient safety incidents, including the locally defined priorities in section five, will address the five recognised stages of Quality Improvement as stated below.
Defining clusters of patient safety incidents and our patient safety incident profile, as detailed in this plan, has allowed us to identify and begin to understand the problem for each patient safety incident issue.
First community will bring together safety learning responses and quality improvement tools to enable continuous learning and improvement. Appropriate measures to test the effectiveness of any planned actions will be identified. Implemented actions will be reviewed using these measures to evaluate their impact on the patient safety incident issue and determine whether they should be adapted, adopted or abandoned.
It is important that others can learn from these pieces of improvement work to support more wide-spread learning and change. Learning will be shared at First Community's Clinical Quality and Effectiveness Group, at quarterly Patient Safety Incident Response Framework (PSIRF) meetings, through the QI Leaders Network, project reporting posters and First News and at First Community's annual Quality Improvement Day to maximise organisation-wide learning.
Definitions:
Patient Safety Incident Investigation (PSII): A patient safety incident investigation (PSII) is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning.
B1465-PSII-overview-v1-FINAL.pdf (england.nhs.uk)
Learning from Lives and Deaths: People with a Learning Disability and autistic people (LeDeR): A LeDeR review looks at key episodes of health and social care a person has received looking for areas that need improvement and where practice has been good.
Post Infection Review (PIR): A review into the circumstances surrounding specific infections to find out improvements, learning and share good practice.
After Action Review (AAR): A method of evaluation to capture outcomes of an activity or event, aiming to capture learning and promote success for the future. learning-handbook-after-action-review.pdf (england.nhs.uk)
First Community staff can access the the GU_PSQ061a After Action Review-Conductors Toolkit v1 and GU_PSQ061b After Action Review: Information for People Participating v1 documents for further information.
SWARM Huddle: Immediately after an incident, staff 'swarm' to the site to find out what happened, how it happened and decide on actions to reduce the risk of recurrence. B1465-Swarm-huddle-v1-FINAL.pdf (england.nhs.uk)
First Community staff can access the GU_PSQ061e Swarm Huddle TOOL v1 document for further information.
Multidisciplinary Team Review: An open discussion to identify key factors and gaps in patient safety incidents for which it is more difficult to collect staff recollections of events either because of the passage of time or staff availability or where there are multiple safety incidents. B1465-MDT-review-v1_FINAL.pdf (england.nhs.uk)
First Community staff can access the GU_PSQ061c Multidisciplinary (MDT) Review TOOL: v1 document for further information.
The diagram below demonstrates how First Community's Patient Safety Responses and plan will be integrated into our quality improvement approach.
The patient safety incident risks for First Community have been profiled. This has been completed both at service level and at an organisational level. During the period 1 April 2026 to 31 March 2027 First Community have undertaken two Patient Safey Incident Investigations (PSIIs). We know that the most frequent reported incidents continue to be falls, pressure ulcers and medicines. However, that does not mean these will provide the most learning and opportunity for improvement. To define our priorities, the patient safety and quality team met with every service to collaboratively review their data. This enabled an open conversation about risk and maximising resources to enable safety improvement and learning.
The following data sources for the previous 12 months has been used at service level and organisational level:
As well as meetings with all clinical services in First Community the following stakeholders were involved:
First Community acknowledges that our patient safety incident and improvement profile may change over time. Therefore, we have implemented processes to ensure that any emerging priorities are identified, at both a service level and an organisational level, to enable safety improvement and learning.
The following data sources will be used at service level and organisational level.
First Community's Quality Committee (Board oversight of Quality) and Clinical Quality and Effectiveness Group (Operational oversight of quality reporting to Quality Committee) hold the authority for the implementation of PSIRF and development of this plan and First Community's Patient Safety Incident Response Policy. This group includes First Community's Patient Safety Partner as a core member to champion the patient voice in the development of this plan.
First Community is committed to clinically led continuous improvement and has embedded annual quality improvement planning which plans improvement activity annually. The governance and reporting framework for quality improvement ensures learning is shared and that improvement is made and sustained. Plans are flexible and are informed by listening and involvement of those who use our services to enable in year modification to respond to arising risks, feedback and incidents.
Planned improvement for the period 1 April 2026 to 31 March 2027 includes the following work that impacts on safety learning and improvement. Please see our Quality Account
Below is a list of patient safety incidents that will be responded to according to national requirements. There will be responses that First Community will lead or be part of involving other partner organisations. Where this is the case First Community will be responsible for the governance around their own actions only. It must be clear in terms of reference or ground rules that each organisation is responsible for implementation and governance of actions. Any actions identified to be enacted by another provider or stakeholder must be discussed with the relevant provider / stakeholder and / or commissioner.
Surrey Heartlands ICB can be involved to maintain oversight depending on the nature of learning and stakeholders involved.
Leading a multi-provider response may be overseen by Surrey Heartlands ICB depending on the nature of learning and stakeholders involved. First Community will alert Surrey Heartlands ICB in the event of a multi-provider learning response, as appropriate.
|
Patient safety incident type |
Required response |
Anticipated improvement route |
|
Incidents meeting the Never Events criteria |
PSII |
Clinical Quality and Effectiveness Group |
|
Death thought more likely than not due to problems in care (incident meeting the learning from deaths criteria for patient safety incident investigations (PSIIs)) |
PSII |
Mortality Review Group |
|
Death of a person with learning disabilities where there is reason to believe that the death could have been contributed to by one or more patient safety incidents/problems in the healthcare provided by the NHS. |
PSII LeDeR Review |
Mortality Review Group |
|
Incidents with Safeguarding Responsibilities where a concern of abuse or neglect has been identified. |
As per safeguarding requirements |
Safeguarding Group |
|
Infections Prevention and Control Outbreak Notification of Infectious Disease |
PIR PSII AAR |
Infection Prevention and Control Group |
First Community have determined our local focus based on stakeholder engagement and findings of our local mapping and profiling. Below is a list of patient safety incidents that will be responded to for learning and improvement:
|
Patient safety incident type or issue |
Planned response |
Anticipated improvement |
New or ongoing priority for learning and improvement |
|
Caterham Dene Ward - Improving communication with relatives |
AAR Multidisciplinary Team Review |
Improve communication between patients, those close to them and the ward staff |
Priority carried over from 2025-2026 |
|
Violence, aggression and abuse - keeping staff safe |
AAR Multidisciplinary Team Review |
Reduce the risk of violence, aggression and abuse towards staff, keeping our staff safe |
Priority carried over from 2025-2026 |
|
Connectivity, Mobile Working & Access to Clinical Systems |
AAR Multidisciplinary Team Review |
Improve connectivity and mobile access to clinical systems. |
New priority for 2026 - 2027 |
|
Other incidents which have resulted in moderate to severe harm, a near miss, or where there is potential for wider learning |
Duty of Candour AAR PSII |
To identify risk and learning in real-time |
N/A |
|
Clusters of incidents |
Multidisciplinary Team Review |
To identify risk and learning in real-time |
N/A |
|
Good or positive care or event |
Multidisciplinary Team Review AAR |
To identify learning in real-time |
N/A |
|
Cross System or multi organisation patient safety incidents |
Where more than one organisation is involved in a patient safety incident, the organisation that identifies the incident is responsible for alerting relevant stakeholders to commence investigation and action. |
N/A |
|
|
Patient safety incident type or issue |
Planned response |
Anticipated improvement |
New or ongoing priority for learning and improvement |
|
Caterham Dene Ward - Improving communication with relatives |
AAR Multidisciplinary Team Review |
Improve communication between patients, those close to them and the ward staff |
Priority carried over from 2025-2026 |
|
Violence, aggression and abuse - keeping staff safe |
AAR Multidisciplinary Team Review |
Reduce the risk of violence, aggression and abuse towards staff, keeping our staff safe |
Priority carried over from 2025-2026 |
|
Connectivity, Mobile Working & Access to Clinical Systems |
AAR Multidisciplinary Team Review |
Improve connectivity and mobile access to clinical systems. |
New priority for 2026 - 2027 |
|
Other incidents which have resulted in moderate to severe harm, a near miss, or where there is potential for wider learning |
Duty of Candour AAR PSII |
To identify risk and learning in real-time |
N/A |
|
Clusters of incidents |
Multidisciplinary Team Review |
To identify risk and learning in real-time |
N/A |
|
Good or positive care or event |
Multidisciplinary Team Review AAR |
To identify learning in real-time |
N/A |
|
Cross System or multi organisation patient safety incidents |
Where more than one organisation is involved in a patient safety incident, the organisation that identifies the incident is responsible for alerting relevant stakeholders to commence investigation and action. |
N/A |
|
A detailed explanation of the various learning response methods available to us can be found in Appendix A.
|
Response Method |
Description |
When to use |
Who can lead this |
Who should be involved |
Time taken to complete |
|
After Action Review (AAR)
|
An after-action review (AAR) is a structured approach for reflection and identifying strengths, weaknesses and areas for improvement. It is a facilitated discussion following an event or activity to enable understanding of the expectations and perspectives of all those involved. AAR is recommended as a key tool to bring about learning and improvement in the Patient Safety Incident Response Framework (PSIRF). |
First Community have chosen AAR as the main model to learn from incident responses, learning from excellence and other improvement work.
An AAR can be used after any activity or event that has been particularly successful or unsuccessful. |
Any trained conductor |
This is identified as part of each AAR. Can be those involved, others involved in the process and multidisciplinary team and service users. |
Between 45 and 90 minutes then time to write up the AAR. |
|
Multidisciplinary Team Review (MDT Review) |
A multidisciplinary (MDT) review is a structured approach for reflection and identifying learning from multiple patient safety incidents or a safety theme. It is a facilitated discussion to enable insights into 'work as done' from all those involved and contributes to the understanding the problem step of Quality Improvement projects. MDT reviews are recommended as a key tool to bring about learning and improvement in the Patient Safety Incident Response Framework (PSIRF). NHS England » Patient safety learning response toolkit |
An MDT review can be used after when there are multiple, similar incidents or to explore a safety theme, pathway or process e.g. admission or discharge related safety events. |
Usually someone who has completed training provided by First Community and / or SEIPS. |
The stakeholders whose insights on 'work as done'. This list will depend on the incident or safety theme being explored. It should include clinical and non-clinical staff who work in the care setting or pathway to which you are applying the tool. |
Each MDT review is different. Likely to be 2-3 hours and be run as a workshop type event. |
|
Patient Safety Incident Investigation (PSII) |
A patient safety incident investigation (PSII) is undertaken when an incident or near-miss indicates significant patient safety risks and potential for new learning. Investigations explore decisions or actions as they relate to the situation. The method is based on the premise that actions or decisions are consequences, not causes, and is guided by the principle that people are well intentioned and strive to do the best they can. The goal is to understand why an action and/or decision was deemed appropriate by those involved at the time. |
When an incident or near-miss indicates significant patient safety risks and potential for new learning. Investigations explore decisions or actions as they relate to the situation. |
A Learning Response Lead. This is a member of staff who has completed the relevant training and is competent to undertake a PSII. A lead will be nominated by the Safety Huddle. |
The investigation team should be formed based on factors including availability, systems-focused safety investigation knowledge and interests. |
Up to 80 hours (not all at the same time) and will take a number of weeks to complete. |
|
Swarm huddle |
A swarm huddle is a post-incident huddle which explores what happened and how it happened in the context of how care was being delivered in the real world (ie work as done) to allow us to learn and improve. Swarm huddles are recommended as a key tool to bring about learning and improvement in the Patient Safety Incident Response Framework (PSIRF). |
A swarm huddle takes place as soon as possible after a patient safety incident occurs allowing safety actions to be implemented immediately. |
Usually someone who has completed training provided by First Community and / or SEIPS. |
Those directly involved in these events. Can also include others involved in the process and multidisciplinary team and service users. |
Up to 30 minutes and then time to write |
|
Version |
Date |
Author |
Status |
Comment |
|
0.1 |
18/07/2023 |
Emma Marcroft Head of Patient Safety and Quality |
DRAFT |
Sent for consultation to PSIRF Implementation Group Members and Surrey Heartlands ICB. |
|
0.2 |
28/07/2023 |
Emma Marcroft Head of Patient Safety and Quality |
DRAFT |
Amended from consultation feedback and version sent to Quality Committee. |
|
0.3 |
10/08/2023 |
Emma Marcroft Head of Patient Safety and Quality |
DRAFT |
Minor updates to service list and formatting. Approval given from Quality committee to submit to ICB led Stakeholder panel. |
|
0.4 |
15/08/2023 |
Emma Marcroft Head of Patient Safety and Quality |
DRAFT |
Content page updated to correct section numbers and improvement added to section 3 title. |
|
0.5 |
08/09/2023 |
Emma Marcroft Head of Patient Safety and Quality |
DRAFT |
Changes made following ICB panel |
|
1 |
12/09/2023 |
Emma Marcroft Head of Patient Safety and Quality |
FINAL |
Final version |
|
1.1 |
10/01/2024 |
Emma Marcroft Head of Patient Safety and Quality Stephanie Teatherton, Quality Improvement Lead |
Draft |
Changes made |
|
1.2 |
29/01/2024 |
Emma Marcroft Head of Patient Safety and Quality Michelle Barnard Quality Lead Surrey Heartlands ICB |
|
Changes made to section 4 to reflect ICB and governance of multi stakeholder learning responses. Submitted to CQE and Quality Committee for approval and ratification. |
|
2 |
27/03/2023 |
Emma Marcroft Head of Patient Safety and Quality Stephanie Teatherton, Quality Improvement Lead |
|
Staff survey results updated for 2023 and quality improvement plans in section 3 amended to reflect work for 2024 / 25 |
|
2.1 |
07/01/2025 |
Emma Marcroft Head of Patient Safety and Quality Stephanie Teatherton, Quality and Patient Safety Improvement Lead |
DRAFT |
Updated for the year 1 April 2025 to 31 March 2026, draft submitted for approval at CQE and ratification at Quality Committee |
|
3 |
02/04/2025 |
Emma Marcroft Head of Patient Safety and Quality Stephanie Teatherton, Quality and Patient Safety Improvement Lead |
FINAL |
Quality Improvement areas for 2025 / 26 added. Final version |
For office use only:
|
Start Date |
1 April 2026 |
End Date |
31 March 2027 |
|
Approved by: |
Clinical Quality and Effectiveness Group |
Responsible Executive |
Jon Ota, Director of Quality and People and Chief nurse |
|
Ratified by: |
Quality Committee |
Version |
3.1 |