Children's social work services Duty of Candour Report 2020-21

Background

The organisational Duty of Candour provision of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 (The Act) and The Duty of Candour Procedure (Scotland) Regulations 2018 set out the procedure that organisations providing health services, care services and social work services in Scotland are required by law to follow when there has been an unintended or unexpected incident that results in death or harm (or additional treatment is required to prevent injury that would result in death or harm).

This report covers Angus children’s social work services residential estate, three children’s residential homes and one respite unit for children with disabilities and or complex needs whom have Duty of Candour reporting responsibility. Angus adult services Duty of Candour report is contained within Angus Health and Social Care Partnership annual report for 2020 to 2021.  

Following our legal requirement when things go wrong and mistakes happen, we have continued to meet with people affected, ensure they understand what has happened, receive an apology, and that social work services in Angus learn from mistakes and where necessary change minimise future risks to individuals using our services.

As part of our duty this annual report highlights the Duty of Candour incident in our services. This short report details between 1 April 2020 and 31 March 2021 children’s social work services in Angus had one reported incident under the Duty of Candour categories noted below. 

Incidents to which the duty of candour applies

Type of unexpected or unintended incident

Number of times this happened

Someone has died

0

Someone has permanently less bodily, sensory, motor, physiologic or intellectual functions

 

0

Someone’s treatment has increased because of harm

1

The structure of someone’s body changes because of harm

0

Someone’s life expectancy becomes shorter because of harm

0

Someone’s sensory, motor or intellectual functions is impaired for 28 days or more

 

0

Someone experienced pain or psychological harm for 28 days or more

 

0

A person needed health treatment in order to prevent them dying

0

A person needing health treatment in order to prevent other injuries

 

0

 

To what extent did we follow the Duty of Candour procedure?

Following the incident where someone’s treatment has increased because of harm all procedures were followed correctly and timelessly. As responsible person we discussed the situation at the time with the person affected and their relative. Within a three week period we met with relevant parties to discuss in an open and transparent manner the outcome of the review of the incident, gather the views of impacted parties and listen to suggestions for improvements. An unreserved apology was given and followed up in writing. As with responsible person’s requirements a full report was provided to the Care Inspectorate and the incident was discussed with Health and Safety colleagues within the council.    

Information about our policies and procedures

As noted above where something has happened that triggers the Duty of Candour, procedures are followed in line with Duty of Candour Operational Instruction. This instruction applies to all health, care and social work staff and details what action staff must take and how staff must react in accordance with our duty to be open, honest and supportive when there is an unexplained or unintended incident resulting in death or harm. Responsible managers of children’s residential and respite units have undergone Duty of Candour training.  

All staff are responsibility for ensuring that the Duty of Candour procedure is followed. The manager records the incidents, informs senior management and reports the incident as appropriate to the Care Inspectorate. When an incident has occurred, the manager and staff review the incident and report findings to the senior manager. This allows for independent review of what happened and identify any changes required or learning for the future.

We know that serious mistakes can be distressing for staff as well as people who use care services and their families. We have counselling support in place for our staff if they have been affected by a Duty of Candour incident and manages meet with staff to debrief following any serious incidents.

What has changed as a result?

Following the incident noted in this report for 2020/21 a full review of all risk assessments in use across the three residential homes and the respite unit was undertaken. I have introduced a revised risk assessment covering all activities undertaken by residences. Learning from the review has been shared with staff across the residential estate at team meetings as well as through individual one to one session with staff involved in the incident. Guidance on accidents has been reviewed and communicated to staff. We continue to make changes to our policies and procedures as a result of Duty of Candour, learning from mistakes, complaints and feedback from those who use social work services.

Other information

The Duty of Candour provision of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 (The Act) and The Duty of Candour Procedure (Scotland) Regulations 2018 continues to keep our focus on the people who use children’s care services in Angus. We are committed to communicating with people openly and transparently recognising that people who use are services have the right to know when things go wrong, as well as when they go well.

As required, we will submit this report to the Care Inspectorate, and we will publish this report on Angus Council website.

For further information in respect of this report, please contact People@angus.gov.uk

Approved on 31 May 2021