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Quality & Safety

Quality and safety are intrinsic to all that the Clinical and Care Professional Leadership programme does. From a governance perspective there are clear lines between the Clinical Forum into the System Quality Group and Safeguarding.

All members of the Clinical Executive Group such as the CNO and Principle Social Worker etc. have a clear focus on quality and safety that will be shared collectively at the board. This allows quality and safety to be discussed from different perspectives as well as providing a link back to their professional infrastructures. 



Coventry and Warwickshire both have effective multi-agency processes in place to identify potential Safeguarding Adult Reviews and Serious Case Reviews for children. Membership is drawn from a very wide range of agencies with social care, police, voluntary sector, probation, education and the full range of NHS provider and commissioning organisations.  This wide range of professionals expertise is used to consider referrals and contribute to formal reviews. The process is genuinely collaborative, open and honest with sound analysis which identifies good practice and lessons to be learnt. Key information is then communicated across all agencies through case summaries, briefings and learning events.
Coventry and Warwickshire Local Authorities are part of a West Midlands wide approach to practice reviews and practice quality assurance. Two Principal Social Workers from other authorities spend two days in the host authority undertaking the practice review, this practice review focus on strength-based practice approaches and the practice conditions in place to support the application in practice. Due to COVID-19, the Peer Challenge Process re-focused to a Pause and Learn approach and Practice Reviews also incorporated learning from the pandemic. In total 29 reviews have been held over the course of the last 5 years. These reviews have been integrated into the Local Authority Peer Challenge process (Weblink )

Leave no doubt – empowering your life choices

Following the outcome of a learning event from a complex case, a number of areas of concern were raised along with particular areas of development for the CCG with regards to the topic areas: Mental capacity. Advanced decision to refuse treatment (ARDT). Clinically assisted nutrition and hydration (CANAH) decision. Lasting power of attorney for health. 
Advanced Decision to Refuse Treatment (ADRT) and Lasting Power of Attorney (LPA) were discussed at the CCG Clinical Executive Group and recommendations from this group were to detail how we as a CCG, can raise awareness of this very important area with our patients, public, stakeholders and clinicians with an aim to enable and normalise conversations surrounding the above areas. It was noted that more patient and primary care education and awareness raising was needed to ensure that patients are aware of the importance of such discussions should they suddenly be taken ill, injured or need end of life care in the future and/or a decision needed to be made on their behalf of future of treatments. 
A Coventry and Warwickshire wide bus campaign covered various geographical areas on 30 bus rears, along with digital content and staff messaging; all campaign materials were created in partnership with the complaints team, patients, clinical leads and a national charity (Compassion in Dying).

System review of unexpected perinatal patient death

A system-wide review of the care and treatment provided for a perinatal patient prior to her unexpected death was commissioned with the aim to identify any cross-system learning and actions required to help prevent similar incidents occurring in the future. A multidisciplinary panel was convened to review documents provided by those services involved in the patient’s pathway, and meet with the patient’s partner. The final report has been tabled at the Local Maternity and Neonatal System (LMNS) Board to implement the recommendations and monitor actions. In addition, the patient’s partner has shared his story/experience of local healthcare services across the pathway to support system learning