PETERBOROUGH COUNSELLING LTD

Patient Safety Policy

Purpose:
This policy sets out Peterborough Counselling Ltd approach to identifying, responding to, and to, and learning from patient safety incidents, in alignment with the national Patient Safety Incident Response Framework (PSIRF).
Commitment to Patient Safety:
Peterborough Counselling Ltd is committed to delivering safe, effective care, person centred care by a Just Culture and psychologically safe environment. Staff are encouraged to report, reflect on, and learn from patient safety incidents without fear of blame. The Being Fair toolkit will guide our approach to supporting staff following incidents.
https://www.england.nhs.uk/patient-safety/patient-safety-culture/being-fair-tool/
Roles and Responsibilities:

The designated safety lead (named individual or role) is accountable for the implementation and oversight of this policy, including PSIRF-aligned investigations and outcomes.
Cambridgeshire and Peterborough Integrated Care Board (ICB): Will be informed of patient safety incidents and will be engaged within the first 24hrs of incident occurrence for additional advice, support, or resources.
All Staff: Must report incidents and actively participate in safety reviews, debriefs, and reflective learning sessions.
The designated safety lead (named individual or role) will ensure that Patient Safety Partners (PSPs) are actively involved in reviewing patient safety incidents, shaping learning responses, and informing improvement actions.

Where appropriate, the Integrated Care Board (ICB) will be engaged to provide input, oversight, or support in these processes. Requests for ICB involvement will be made as required, in alignment with the Patient Safety Incident Response Framework (PSIRF) and to promote shared learning and continuous service improvement.

4. Recognising and Reporting Incidents:

All patient safety incidents must be reported promptly to the designated safety lead. Incidents include any unintended or unexpected events that could have or did lead to harm.

Report using (name system) and escalate to ICB / other regulatory body
Promote proactive identification through staff meetings, and informal feedback

Response to Incidents:
All patient safety incidents will be categorised and responded to based on the level of actual or potential harm, the risk of recurrence, and the opportunity for learning. Responses will be proportionate not all incidents require a full investigation. The organisation will use the following response types:

Category A: Low Harm / No Harm / Near Miss

Examples: Incorrect documentation, minor errors with no patient impact.
Response:
- Informal reflection during team huddles or supervision
- Shared learning within local team
- No formal investigation required

Category B – Moderate Harm or Repeated Low Harm

Examples: Delayed care causing short-term impact, repeated missed observations.
Response:
- Structured review using a SWARM huddle (short, focused multidisciplinary discussion)
- Or an After Action Review (AAR)
- Identifies contributory factors, system issues, and immediate actions
- Learning logged and shared with staff

Category C – Severe Harm or Death

Examples: Significant deterioration, avoidable harm, or safeguarding-related events.
Response:
- Formal PSIRF-aligned Patient Safety Incident Investigation (PSII)
- Involvement of ICB where needed (e.g., system-level learning or oversight)
- Includes interviews, timelines, contributory factor analysis
- Findings reviewed with PSPs (Patient Safety Partners)
- Family and staff involved in learning and communication (Duty of Candour)

Note: The decision on response type will be made by the Patient Safety Lead within 48 hours of the incident being reported. The rationale for the response level must be documented.

Our response will be proportionate, and may include:
Team reflection or huddles
Structured SWARM huddles to rapidly assess contributing factors and agree immediate actions
After Action Reviews (AARs) or formal investigations for moderate/severe harm events
ICB input for complex cases or system-wide learning opportunities
Documentation and communication with patients/families in line with Duty of Candour

Learning and Improvement:

Learning will be extracted from all incidents, shared across the organisation, and used to:

Identify recurring themes and gaps
Share learning across the team and organisation
Adjust practice, policy, or training
Take practical steps to reduce future risk
Collaborate with PSPs and the ICB for broader insight and system-wide learning

Governance Structure and Learning Flow Chart:

Regular review of incidents and trends
Oversight of learning actions and their effectiveness
Reporting to the ICB as appropriate

Incident Occurs

⬇

Report to Safety Lead

⬇

Inform ICB

⬇

Initial Assessment → Decide Response Type (e.g., SWARM, AAR, full investigation)

⬇

Findings Shared with ICB, Wider Team

⬇

Action Plan Developed & Monitored

⬇

Organisational Learning & Policy Update

Staff Support:

Peterborough Counselling Ltd recognise the emotional impact incidents can have. Staff will be proactively offered:

Structured team debriefs
Reflective sessions or external clinical supervision
Referral to support services (eg BACP for counselling, occupational health)

Involving Patients and Families:

We are committed to open and honest communication in line with the statutory Duty of Candour.

Patients and families will be informed of patient safety incidents in a timely, compassionate, and transparent manner, as required under the Duty of Candour.
Where appropriate, they will be involved in learning and improvement discussions as part of our commitment to continuous improvement under the Patient Safety Incident Response Framework (PSIRF).
Their insights and experiences may inform system changes, contribute to service design, or shape staff training content to help prevent future incidents and improve safety outcomes.

Monitoring and Review:

This policy will be reviewed annually, or sooner if required by service changes or updated national guidance
Incident themes and response effectiveness will be monitored via clinical governance reports
Findings and progress updates will be shared with the ICB as appropriate