Duty of Candour Annual report 2020 – 2021

1.0 Introduction and Context.

All Health and Social Care professionals have a responsibility to be honest with service users (and by proxy Call – in Homecare) when things go wrong. The statutory organisational duty of candour has been developed to be in close alignment with the requirements of the professional duties of candour and is the procedure that organisations providing health services, care services and social work services in Scotland are required by law to follow.

This legal requirement means that when an unintended or unexpected incident (adverse event) arising from the care and/or treatment they have provided results in death (extreme), severe (major) or moderate harm as defined in the health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016, the service user affected must understand what has happened and receive an apology and the company must establish mechanisms through which learning is gained about how to improve for the future.

An element of the duty, defined within the Act, is that organisations provide an annual report on how the duty of candour is implemented across services. This short report describes how Call – In Homecare (Hereafter the Company) has applied the Duty of Candour during the period 1 April 2020 to 31 March 2021.

2.0 Rationale for applying the Duty of Candour Procedure.

Duty of Candour doesn’t apply to situations where a service users condition worsens due to the natural progression of an illness. There are nine rationales that can be applied to adverse event records with harm to help identify when the duty of candour procedure applies, when, because of actions instigated by a colleague of the company:

• A service user dies.
• A service user incurs permanent lessening of bodily, sensory, motor, physiological or intellectual functions.
• A service users’ treatment is increased.
• The structure of a service users’ body is changed.
• A service users life expectancy is shortened.
• A service users’ sensory, motor, or intellectual functions was impaired for 28 days or more.
• A service user experienced pain or psychological harm for 28 days or more.
• A service user needed health treatment to prevent them dying.
• A service user needed health treatment to prevent other injuries as listed above

When a duty of candour event occurs, the company is required to:

• Alert the service user (and their family if appropriate) as soon as practicable, advising them of what may have happened and offer an appropriate apology based on the available information.
• Inform the Care Inspectorate.
• Complete a detailed investigation which:
  • Establishes the facts of what went wrong.
  • Assesses whether what went wrong was caused by a deliberate act of omission / commission.
  • Looks at what could be implemented to reduce the risk of a reoccurrence to the lowest level possible.
  • Makes binding recommendations on the above.
• The service user (and their family if appropriate) harmed by the event should be advised of the outcome of the investigation and a meeting arranged to discuss its findings.
• If appropriate the company must offer to remedy, as far as practicable what went wrong. This may include additional treatment.
• Following this a full written apology should be given.
• Any recommendations made in the report should be implemented.

3.0 Duty of Candour in the context of risk management.

The company has in place an incident reporting policy and associated procedure. All Colleagues are expected to report incidents to their coordinator who will assess, as appropriate, with reference to the Duty of Candour policy, whether a notification is required.

4.0 Number of Duty of Candour Incidents in 2020 – 2021.

There were 0 reported incidents in this period that required a Duty of Candour notification.

5.0 Learning.

Although there were no Duty of Candour Incidents reported several quality improvement interventions are planned:

1. Review of the Incident reporting policy.
2. Development of Risk Management Strategy and associated policy and procedure.
3. Development of toolkits to aid colleagues in assessment of risk, reflective practice, and incident reporting.

6.0 Summary.

Whilst there were no reported Duty of Candour Incidents in 2020 – 2021 the company has recognised the need to further enhance its risk management arrangements.

We will report on progress with implementing these in the 2021 – 2022 report.