Learning Aim C


Compassion in Practice Campaign

  • Support the people we serve to manage their own health and well being 
  • Improve clinical outcomes and enhance patient safety  
  • Support the substantial expansion of community services through delivery of excellent core services for adults and children and the development of ambulatory services
  • Use resources efficiently to enhance our ability to improve services
  • Develop the organisational capacity to deliver visions and objectives

Compassion in Practice was built on the values of the 6Cs (Care, Compassion, Communication, Courage, Competence, Commitment) and delivered improvement programmes through six work streams called Action Areas:

  • Helping people to stay independent, maximising well being and improving health outcomes.
  • Working with people to provide a positive experience of care.
  • Delivering high qualitiy care and measuring the impact of care.
  • Building and strengthening leadership.
  • Ensuring they have the right staff, with the right skills, in the right place.
  • Supporting positive staff experience.
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Jessica Chapman and Holly Wells

Although the girls did walk past his house they did not leave. Huntley attempted to coax the girls into the house by saying their teaching assistant was inside. Huntley claims that Holly fell into the bathtub became unconscious and drowned. And he smothered Jessica to hide her screams, which was the cause of her death. He then burnt their bodies in an attempt to hide the evidence. Due to the badly burnt bodies the pathologist report came back inconclusive in relation to whether Huntley’s claims were true.

An inquiry led by Sir Michael Bichard was set up to investigate this tragedy. One of the key recommendations of the report was that there should be a statutory agency with responsibility for vetting all individuals wanting to work with children or vulnerable adults whether, as a paid member of staff or as a volunteer. This was initially the responsibility of the criminal records bureau (CRB) set up in 2002. In 2012 the responsibility for vetting staff and volunteers was given to the Disclosure and Barring Service (DBS).

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The Cavendish Report

  • In 2013, the Francis Inquiry reported on the standard of care at the Mid Staffordshire NHS Trust. 
  • Concerns were raised in 2007 by the Healthcare Commission about the apparent high death rate. 
  • The final report did not conclude that the high number of deaths was caused by the lack of provision, but serious weaknesses were identified in the quality of care that was provided.
  • As a result of these concerns, many investigations, including the Francis Inquiry, leading to reports of widespread weaknesses in the quality of care within the trust.
  • These included:
  • Chronic staff shortages
  • Patients having inadequate access to food and water
  • Patients left in unclean bedding
  • A failure in the management and leadership of the trust.
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The Cavendish Report continued...

  • Common training standards – all healthcare assistants should complete a certificate in ‘fundamental’ care before they can look after patients unsupervised
  • Career progression – talented care workers will be able to progress into nursing and social care through the creation of a ‘Higher Certificate of Fundamental Care’. This will ensure they have a route to progress in their careers and an opportunity to use their vocational experience of working as healthcare assistant to enter the nursing profession
  • New job title – HCAs who completed the certificate should be allowed to use the term ‘nursing assistant’ in a bid to reduce the number of current job titles held by support workers
  • Caring experience – the Nursing and Midwifery Council should make caring experience a prerequisite to starting a nursing degree and review the contribution of vocational experience towards degrees
  • Recruitment – directors of nursing should take back responsibility for the HCA workforce from human resources departments. Employers should also be supported to test the values, attitudes and aptitude of future staff for caring at the recruitment stage
  • Quality assurance – Health Education England, with Skills for Health and Skills for Care, should develop proposals for a rigorous system of quality assurance for training and qualifications, which links to funding outcomes, so that money is not wasted on ineffective courses
  • Poor performance – the legal processes for challenging poor performance should be reviewed so that employers can be more effective in identifying and removing any unsatisfactory staff.
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The Mid Staffordshire NHS Trust

  • Staff shortages
  • Lack of food and water for patients
  • Beds not changed when dirty
  • Raising concerns was discouraged and failures in managements.
  • Problems were too often assumed to be the responsibility of others
  • They seemed to care more about the needs of the hospital staff than the patients
  • They had an willingness to tolerate the poor standards of patient care
  • They failed to accept and respond to complaints
  • There was a failure of different teams to communicate and share their concerns
  • They caused harm and death to patients due to avoidable failures in care that should have been dealt with as a criminal offence (rather than a regulatory or civil matter)
  • NHS staff, including doctors and nurses, should have a legal ‘duty of candour’ – so they are obliged to be honest, open and truthful in all their dealings with patients and the public
  • A single regulator of both quality of care and financial matters should be created
  • There should be a ‘fit and proper’ test for hospital directors, similar to those set for football club directors
  • A clear line of leadership needs to be established, so it is always clear who is ultimately ‘in charge’ when it comes to a particular patient
  • Uniforms and titles of healthcare support workers should be clearly distinguished from those of registered nurses
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Baby P - Peter Connelly

  • December 2006 - Connelly is arrested after bruises are spotted on the boy's face and chest by a GP.
  • January 2007 - The boy is returned home after being put in the care of a family friend.
  • February 2007 - A whilstlerblower, former social worker Nevres Kemal, sends a letter about her concerns over alleged failings in child protection in Haringey to the department of health.
  • April 2007 - Baby P is admitted to North Middlesex hospital with bruises, two black eyes and swelling on the left side of his head.
  • May 2007 - After seeing marks on the boy's face, a social worker send Baby P to North Middlesex where 12 areas of brusises and scratches are found. Connelly is re arrested.
  • July 2007 - Injuries to Baby P's face and hands are missed by a social worker after the boy is deliberately smeare with chocolate to hide them.
  • August 2007 - Police tell Connelly she will not be prosecuted after her case is considered by the Crown Prosecution Service.
  • August 2007 - Baby P is found dead in his cot. 
  • Lord Laming conducted a review to establish why, despite the changes in legislation, the tragedy had occurred. He found that yet again communication had been poor practise unprofessional and the standards of care inequalities. As part of his review, Lord Laming recommended that there should be.
  •  A review of the recruitment, training and supervision of social workers to ensure that they received better protection training. 
  • Improved safeguarding training for staff with a responsibility for the care of children.
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Victoria Climbie

  • Living and sleeping in a bath in an unheated bathroom, bound hand and foot inside a bin bag, lying in her own urine and faeces.
  • Food would be cold and would be given to her on a piece of plastic while she was tied up in the bath. She would eat it like a dog, pushing her face to the plate.
  • Manning said that Kouao woukd strike Victoria on a daily basis with a show, a coat hanger and a wooden cooking spoon and would strike her on her toes with a hammer. Victoria's blood on Manning football boots.
  • Manning admitted that at times he would hit Victoria with a bicycle chain.
  • The post mortem examination revealed that Victoria's lungs, heart and kidneys had all failed.
  • There was recorded evidence of no fewer than 128 seperate injuries to her body. 
  • Every Child Matters (ECM) was launched in 2003
  • This was to ensure that all children, regardless of their background, should have the chance to reach their full potential by reducing levels of ill health, eradicating abuse and neglect and improving educational success. 
  • The five outcomes to achieve for all children to have this are for them to: - Stay safe - Be healthy - Enjoy and achieve - Make a positive contribution - Achieve economic wellbeing
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