When people move between hospital and a care home, it is quite common for something to go wrong with their care that does or could affect their safety. This is called a safety incident. Some examples include medicines being lost or delayed, or important documents can contain mistakes or go missing. It is important to find out when and why safety incidents happen so that improvements can be made. Finding this out does not happen enough because care homes and hospitals sometimes have different priorities. They also have different understandings of what unsafe care means.
Because of these different priorities, it can be difficult for care homes, hospitals, or even organisations that oversee them, to learn from safety incidents. As such, this study aims to understand how care homes and care home staff report safety incidents when a person moves between hospital and care home. Using this understanding, we aim to work with care homes and hospitals to jointly design a better way of reporting and learning from safety incidents.
The study will be split into two parts that run alongside each other. During the first part (workstream 1), we will review how care homes respond to safety incidents. This will include looking at what policies exist, what technology is used and how reports are captured. This review will be desk-based, combining internet searches, telephone interviews and academic papers. From this, we will create categories of the different systems being used to capture safety incidents. During the second part (workstream 2), we will work with a small number of care home organisations in North East and South West England, covering different types of care homes. We will begin by speaking with care home staff to find out how they report incidents. Separately, we will also speak with staff from non-care home organisations who are involved in people moving between hospital and care home. We will then review the information that the care homes hold, using a method that we have developed and used previously.