Version No:

1

OG Status:

Fully open

Author Section:

Public Services Sector

Issue Date:

20.07.12

Review Date:

20.07.14

To:

FOD operational staff, Specialist inspectors, Complaints Handling Officers, Complaints Support Officers

Summary

This guidance introduces and explains a liaison agreement between CQC and HSE.  The agreement provides a framework to co-ordinate activities and share appropriate information concerning very serious incidents and investigations in healthcare in England.  It also covers sharing more general information.

Introduction

The agreement, modelled on the Work-related deaths protocol, was developed to ensure that HSE can be notified early about serious incidents and that HSE and CQC can share relevant information effectively and consistently.

The agreement explains in detail the circumstances in which it applies, which are summarised in Appendix 1 to this guidance.

Whilst it particularly applies to the death of, or serious injury to, patients that fit our criteria for investigation, the agreement also applies where we have information that it would be in the interest of patients to share with CQC.  This may include complaints relating to patient care, or evidence of systemic management failure that may adversely affect their safety or care. 

It sets out the principles for effective liaison, describes criteria that will help inspectors decide when and how to liaise and sets out specific circumstances under which HSE and CQC should liaise with each other. 

For the purposes of this guidance, situations where the agreement applies are referred to as ‘relevant incidents’. 

Action

Inspectors should become familiar with and implement the Liaison agreement when dealing with healthcare organisations. 

The relevant inspectors/other staff should:

• Contact CQC locally and inform the Health and Social Care Services Unit (see SIM 07/2012/05 – fully closed and available internally to HSE only – for contact details) when made aware of a relevant incident by a duty-holder, via a complaint, or through inspection or investigation;
• Make early contact with CQC when made aware of a relevant incident by the Health and Social Care Services Unit;
• Inform the Health and Social Care Services Unit when made aware of a relevant incident by CQC;
• Record their decisions resulting from application of the agreement with CQC
  • as a COIN note where HSE is investigating, or
  • where HSE is not investigating, as an email to HSE’s Public Services Sector - publicservicessector@hse.gsi.gov.uk
• Ensure normal consultation in response to requests for HSE disclosure of any information originating from CQC (i.e. following the requirements of Data Protection Act 1998, Freedom of Information Act 2000, and Medical Records Act 1990); and,
• Contact the Health and Social Care Services Unit if advice is needed in applying the agreement to arrive at a final decision, or if there are any other concerns.

For the purposes of applying the agreement, ‘senior supervisory officer’ refers to FOD Principal Inspectors and CQC’s Deputy Regional Directors (see Annex 4 of the agreement).

Background

The CQC and HSE have different roles and responsibilities in the regulation of health and social care, and the agreement refers to the operational practices of each organisation that underpin its implementation.

At present the agreement only covers healthcare settings regulated by CQC. HSE intends to develop it further with other regulators, e.g. local authorities, so that it covers both health and social care.  CQC and HSE inspectors may find it helpful to follow the principles in the agreement in other situations in which both regulate.

Organisation

No special visits are required, but the Health and Social Care Services Unit welcomes any feedback about this approach.

Further References

Guidance on health and safety risks in health and social care is provided on the HSE health and social care website.

Contacts

Health and Social Care Services Unit, Public Services Sector
publicservicessector@hse.gsi.gov.uk

Appendices

Appendix 1:  Application

This agreement applies to unexpected deaths of service users and serious safety incidents resulting in an injury to a service user, where all of the following circumstances have been met:

• both HSE and CQC have regulatory responsibilities;
• the unexpected death or injury of a service user has arisen out of, or in connection with work, within healthcare settings;
• the death or injury cannot clearly be attributed to a clinical decision;
• the criteria for notification to CQC have been met; and,
• HSE’s Incident Selection Criteria or HSE’s guidance on responding to public safety incidents where Section 3 of HSWA applies have been met.

Further information about these circumstances is given in Annexes 3 and 5 of the agreement.

The agreement will also apply where matters of concern that have a realistic potential to cause deaths or major injuries that fit the above circumstances come to CQC or HSE’s attention.

There may be cases in which it is difficult to determine whether this agreement applies.  Each case will need to be considered according to its individual circumstances. Where there is uncertainty, CQC and HSE will discuss the facts of the case and agree an appropriate course of action.

The agreement also applies to more general sharing of information (for example about complaints, or evidence of systemic management failure) where this is clearly in service users’ interests.