Patient Safety Incident Response Framework (PSIRF)

Introduction and purpose

HomeLink Healthcare (HLHC) is a clinician-led specialist Hospital at Home provider delivering safe, high-quality clinical care to NHS patients in their homes since 2016. By working collaboratively with hospitals, ICBs, consultants, local authorities, community providers, and GPs, we prevent avoidable hospital admissions and support patients to return home sooner.

We deliver a range of Hospital at Home pathways, including:

• Early Supported Discharge
• Discharge to Assess
• Virtual Wards
• Intermediate Care at Home
• Reablement and Rehabilitation
• Admission Avoidance
• Bridging Packages of Care

HLHC is a named supplier on the NHS SBS Framework Agreements, enabling commissioners to rapidly mobilise services within approximately 12 weeks.

This policy sets out HLHC’s approach to meeting the NHS Patient Safety Incident Response Framework (PSIRF) requirements. It describes how HLHC will respond to patient safety incidents in a way that supports learning, reduces harm, and continually improves the safety of the services we deliver.

This policy adopts a systems-based approach, recognising that incidents rarely have a single cause. Learning responses therefore focus on identifying contributory factors, not assigning blame or determining liability. Processes such as HR investigations, coronial enquiries, and claims management sit outside the scope of this policy.

This policy ensures that all HLHC staff:

• Understand the requirements of PSIRF
• Receive training to apply PSIRF in practice
• Use Radar to report incidents and concerns
• Are confident to speak up about patient safety
• Engage compassionately with patients, families, and carers
• Understand Duty of Candour and PSIRF terminology.

Who this policy applies to

• All HLHC employees (substantive and bank)
• Patients, carers, relatives, and advocates engaging with patient safety processes

All employees are responsible for understanding and adhering to this policy.

Definitions

• PSIRF: Patient Safety Incident Response Framework
• PSIRP: Patient Safety Incident Response Plan
• PSP: Patient Safety Partner
• PSI: Patient Safety Incident
• PSII: Patient Safety Incident Investigation
• LFPSE: Learning From Patient Safety Events

Duties and responsibilities

Internal Oversight

HLHC Clinical Leads responsible for incident oversight will complete:

• A one-day patient safety incident oversight training
• Formal training in learning from patient safety incidents
• NHSE Patient Safety Syllabus Levels 1 & 2

Monitoring of safety improvements will occur via:

• Expert Advisory Groups (e.g., Medicines Management, Falls, Infection Control)
• Patient Safety Group
• Quality & Safety Meetings with external advisor oversight
• Annual Quality Report

External Oversight

External oversight includes:

• Northamptonshire ICB and NHSE (supporting PSIRP/PSIRF implementation)
• Care Quality Commission (CQC)
• Learning From Patient Safety Events (LFPSE) national reporting

The Policy

HLHC Patient Safety Culture

HLHC’s values of compassion, collaboration, and commitment underpin our approach to patient safety. We foster psychological safety, so staff feel safe to raise concerns and share ideas without fear of blame.

Just Culture

The Nursing and Midwifery Council (2021) defines Just Culture as one that “balances fairness, learning and accountability.” HLHC is committed to a Just Culture where staff, patients, and families can expect:

• Kindness and compassion
• Truthfulness when things go wrong
• Inclusion in investigations and safety discussions
• Access to written incident responses

To support Just Culture, HLHC provides multiple avenues for speaking up:

• Open-door sessions with the Senior Leadership Team
• Freedom to Speak Up Champions
• Happiness Index (employee-voice platform)
• Radar (incident reporting system)
• Colleague Council

All staff, including the Board, complete Level 1 NHSE Patient Safety Training. Leaders complete Levels 1 & 2 and duty of candour training.

Psychological Safety

Psychological Safety is “the belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes” (Edmondson, 1999). HLHC promotes psychological safety, so staff feel confident to report concerns that affect patient safety.

Patient Safety Partners (PSPs)

PSPs are trained volunteers who work with HLHC to improve patient safety. They:

• Sit on the Patient Safety Group
• Contribute to safety projects
• Participate in working groups
• Support development of improvement actions

Their involvement ensures patient voice informs safety decisions.

Engagement of PSPs

Involving patients, families, and carers supports:

• More effective learning from incidents
• Improvement of patient experience
• Transparency and shared understanding

PSP Activities

PSPs may:

• Participate in interviews with staff and families
• Support equality and inclusion assessments
• Take part in recruitment and interviews
• Help patients and families raise concerns
• Contribute to service pathway understanding and safety improvements

Responding to Health Inequalities

During incident review and investigation, HLHC will consider whether protected characteristics (age, disability, race, sex, etc.) may impact a person’s ability to engage. Adjustments will be made to ensure full and meaningful involvement in learning responses.

Engaging Patients, Families, and Staff After a Patient Safety Incident

HLHC ensures compassionate engagement after an incident, including:

• Helping individuals understand what happened
• Answering questions
• Providing signposting to support services

Patient Safety Incident Response Planning

HLHC follows national PSIRF guidance and investigates: Nationally mandated incidents, including:

• Never Events
• Learning from Patient Deaths criteria
• Child deaths
• Deaths of individuals with a learning disability
• Safeguarding-related incidents

HLHC may also investigate incidents where:

• Frequent no-harm incidents occur
• Trends indicate systemic issues
• A patient experiences ≥2 falls with harm
• Incidents that fall outside of HLHC’s known safety profile or those that involve new technologies, rare procedures, or unexpected patterns of care.
• Category 3 or 4 pressure ulcers develop under HLHC care
• Severe medication errors occur

Investigation Methods

HLHC uses nationally recognised tools, including:

• SWARM Huddles
• Action After Review
• Patient Safety Audits
• Round-table discussions
• Case note reviews

All methods require compassionate engagement and result in a detailed report shared with all involved.

HLHC Patient Safety Incident Response Plan (PSIRP)

The PSIRP is a 12–18-month living document describing:

• Priorities based on incident analysis
• Improvement plans completed and outstanding
• Proportionate responses to incident types

It is reviewed and updated regularly and published on our website.

Patient Safety Incident Response Arrangements

HLHC uses Radar to record and investigate all incidents. Key forums include:

• Weekly Adverse Event Meetings
• Monthly thematic reviews
• Quarterly Quality and Safety report

Decision-Making and Learning Priorities

Based on four years of data, HLHC has two priority areas:

• Medication management
• Falls prevention

New learning forums include:

• Weekly Adverse Event Meeting
• Bi-monthly Patient Safety Group

Cross-System Incidents

Joint governance arrangements with commissioners ensure shared reporting, investigation, and learning across systems.

Investigation Timeframes

• Swarm/Huddle: within 24 hours
• After Action Review: within 3–5 days
• PSII: within 3 months (maximum 6 months)

Patients, families, and staff are updated throughout.

HLHC Patient Safety Culture

HLHC’s values of compassion, collaboration, and commitment underpin our approach to patient safety. We foster psychological safety, so staff feel safe to raise concerns and share ideas without fear of blame.

Just Culture

The Nursing and Midwifery Council (2021) defines Just Culture as one that “balances fairness, learning and accountability.”
HLHC is committed to a Just Culture where staff, patients, and families can expect:

• Kindness and compassion
• Truthfulness when things go wrong
• Inclusion in investigations and safety discussions
• Access to written incident responses

To support Just Culture, HLHC provides multiple avenues for speaking up:

• Open-door sessions with the Senior Leadership Team
• Freedom to Speak Up Champions
• Happiness Index (employee-voice platform)
• Radar (incident reporting system)
• Colleague Council

All staff, including the Board, complete Level 1 NHSE Patient Safety Training. Leaders complete Levels 1 & 2 and duty of candour training.

Psychological Safety

Psychological Safety is “the belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes” (Edmondson, 1999). HLHC promotes psychological safety, so staff feel confident to report concerns that affect patient safety.

Patient Safety Partners (PSPs)

PSPs are trained volunteers who work with HLHC to improve patient safety. They:

• Sit on the Patient Safety Group
• Contribute to safety projects
• Participate in working groups
• Support development of improvement actions

Their involvement ensures patient voice informs safety decisions.

Engagement of PSPs

Involving patients, families, and carers supports:

• More effective learning from incidents
• Improvement of patient experience
• Transparency and shared understanding

PSP Activities

PSPs may:

• Participate in interviews with staff and families
• Support equality and inclusion assessments
• Take part in recruitment and interviews
• Help patients and families raise concerns
• Contribute to service pathway understanding and safety improvements

Responding to Health Inequalities

During incident review and investigation, HLHC will consider whether protected characteristics (age, disability, race, sex, etc.) may impact a person’s ability to engage. Adjustments will be made to ensure full and meaningful involvement in learning responses.

Engaging Patients, Families, and Staff After a Patient Safety Incident

HLHC ensures compassionate engagement after an incident, including:

• Helping individuals understand what happened
• Answering questions
• Providing signposting to support services

Patient Safety Incident Response Planning

HLHC follows national PSIRF guidance and investigates:
Nationally mandated incidents, including:

• Never Events
• Learning from Patient Deaths criteria
• Child deaths
• Deaths of individuals with a learning disability
• Safeguarding-related incidents

HLHC may also investigate incidents where:

• Frequent no-harm incidents occur
• Trends indicate systemic issues
• A patient experiences ≥2 falls with harm
• Incidents that fall outside of HLHC’s known safety profile or those that involve new technologies, rare procedures, or unexpected patterns of care.
• Category 3 or 4 pressure ulcers develop under HLHC care

• Severe medication errors occur

Investigation Methods

HLHC uses nationally recognised tools, including:

• SWARM Huddles
• Action After Review
• Patient Safety Audits
• Round-table discussions
• Case note reviews

All methods require compassionate engagement and result in a detailed report shared with all involved.

HLHC Patient Safety Incident Response Plan (PSIRP)

The PSIRP is a 12–18-month living document describing:

• Priorities based on incident analysis
• Improvement plans completed and outstanding
• Proportionate responses to incident types

It is reviewed and updated regularly and published on our website.

Patient Safety Incident Response Arrangements

HLHC uses Radar to record and investigate all incidents.
Key forums include:

• Weekly Adverse Event Meetings
• Monthly thematic reviews
• Quarterly Quality and Safety report

Decision-Making and Learning Priorities

Based on four years of data, HLHC has two priority areas:

• Medication management
• Falls prevention

New learning forums include:

• Weekly Adverse Event Meeting
• Bi-monthly Patient Safety Group

Cross-System Incidents

Joint governance arrangements with commissioners ensure shared reporting, investigation, and learning across systems.

Investigation Timeframes

• Swarm/Huddle: within 24 hours
• After Action Review: within 3–5 days
• PSII: within 3 months (maximum 6 months)

Patients, families, and staff are updated throughout.

Safety Actions and Improvement Monitoring

HLHC uses the NHSE Safety Action Development Guide (2022) and the SHARE De-brief Tool. Safety actions are monitored:

• In regional and local team meetings
• At commissioner service reviews
• Centrally by the Clinical Director

Safety Improvement Plans

Safety improvement plans consolidate findings from incidents, complaints, surveys, and inequalities data. They are reviewed by the Patient Safety Group and inform organisational change.

Complaints and Appeals

HLHC follows the Complaints, Concerns and Comments Policy. Where possible, concerns should be resolved locally with the service manager. Patients receive a Patient Information Leaflet outlining how to raise concerns.

Impact analysis

This policy clarifies roles, responsibilities, and processes for managing patient safety incidents, promoting openness, compassion, and a Just Culture.

Training requirements

HLHC delivers a comprehensive PSIRF Training Plan including:

• NHSE Patient Safety Syllabus Level 1 (mandatory for all staff)
• Level 2 for leaders involved in investigations
• Formal training in learning responses and Duty of Candour
• PSIRF and Just Culture overview at induction

Compliance is monitored via PeopleHR and Power BI.

Monitoring of policy compliance

Compliance is monitored by the Patient Safety Group and assured through the Quality & Safety Board.

Please view our Patient Safety Incident Reporting Plan here.