Dekker at ClockView

Just and Learning Culture - Our Journey

Our journey

We know the focus of how we do things in a just way has to resonate with staff but it must also be just for patients, carers and their families. This won’t drop into place overnight because we will have to work out how to manage the tension of wanting all aspects of what we do to be open and transparent while simultaneously not accepting that we can be tolerant of every and any action.

There is obviously much work to do, but the overwhelming feedback from people has been positive, we are at the beginning of a long journey, but our experience so far is our Just and Learning Culture approach is having an impact.


When Mersey Care began to formally address our culture in 2016, we had a significant number of disciplinary cases and associated suspensions. This was problematic for safe service delivery and seriously affected the health and wellbeing of colleagues.

Together managers and staff side realised that something significant had to change. This led us to looking, in partnership, for alternative solutions.

We now seek to ensure employees who may be subject to disciplinary investigation are able to contribute information to that decision making process. The significant focus on gathering appropriate information in the initial stages of investigation is placed on understanding the incident. As an outcome, it may be that there are a number of learning points which may be linked to policy issues, system issues, training issues, performance issues or in some cases conduct issues

Analysis of the cases from the previous year had shown that only 52% of investigations resulted in there being a case to answer at a formal disciplinary hearing with all of these cases resulting in some level of formal sanction. Attention was therefore focused on the initial stages of the process and how we determined that an investigation was required.

We introduced template documentation which was probably one of the most significant things in reducing cases. Whilst the documentation itself is simple, it encouraged those responsible for making the decision to ensure the appropriate information had been obtained and considered before deciding to instigate formal proceedings, and the rationale was then clearly documented.

Where possible and appropriate, the trust worked to make sure those who may be subject to disciplinary investigation were able to contribute information to the process. The HR Team will still advise managers with gathering appropriate information in the initial stages but the focus is very much on investigating and understanding the incident first, changing questions from ‘who’ to ‘what’ to get to a place of understanding.

There has since been a significant reduction in disciplinary cases. One of the four clinical divisions saw 64 percent reduction in disciplinary cases between 2016 and 2017. In the period from 2018, 199 investigations and 57 suspensions have been avoided. This has a positive impact on many costs, as well as on morale and, crucially, continuity of care. Find out more about what this means for our own culture and staffing on this page. Find out more about development and training on this page.

Not Walking on Eggshells

I really enjoy my role in the trust, offering clinical support and advice to teams in a specialist area of practice. Ward teams are really great on my patch and really receptive to making changes to improve care for our patients and I am proud of working together with so many good people.

If I’m honest occasionally in the past there has been real resistance from groups of staff to measures that I felt have really needed to be undertaken to improve care.
On one occasion it was suggested to me that my approach amounted to a ‘disciplinary issue’ when I was simply disagreeing (really politely) with the manager of particular service about care. There have been times when this has made me feel a bit vulnerable and a bit threatened, feeling that I am breaking some rule or policy that maybe I was unaware of. You just get yourself into a panic when you hear the word ‘disciplinary’.
Your mind can run away with you…”Am I right?”, “Could I get into trouble for accidentally antagonising people?”, “Should I pull back from my position to keep me safe, to protect my job?”  
What I think ‘Just and Learning Culture’ gives you is more confidence to stick to your guns on behalf of good patient care. 99% of the time this isn’t an issue and the teams I work with are keen to get on board with change, even if they are really busy.
It’s okay to have different views on care, but you have to feel safe to express them, even if they are difficult for some people to hear. I don’t want to feel that I am walking on eggshells, so it helps.
Social Media Alert!

This is an example from a colleague who has been working for the Trust for over a decade. She had recently given birth and following this experienced significant sleep deprivation and emotional issues as a result. 

The colleague was trying to manage her full time work obligations with minimal or no sleep some nights, which lasted for a considerable period of time. At the time she knew was struggling and didn’t want the negative effects to take over. One of her way of coping was to fixate on other things so that she did not concentrate her thoughts on the lack of sleep.
Earlier this year she became fixated with a national social media campaign relating to another Trust.  The case involved the treatment of a patient and her perception was that she was in support of the patient. At the time her frame of mind prevented her from recognising that this had implications for her employment in the NHS.  The incident involved her sharing someone else’s post without fully understanding the implications.

The Trust approached our colleague to gain a full understanding of her circumstances and the situation. Following this meeting it was reviewed against the Just and Learning Culture and not to pursue a full disciplinary investigation.

She appreciated this direct approach as it gave her a chance to put her side of the story and then for the Trust to make an informed decision based on this information. She believes that if a full investigation would have been required then this would have had a profound effect on her because of where she was mentally during that time.

The colleague has said that this is a one off incident in her decade and more employment and the JLC process has allowed her to learn from the experience rather than being punished for a silly mistake. 

She hopes that by sharing her experience others will be more aware of how although social media may be a trivial part of your day but it can impact significantly on your employment.

Under Pressure

Pressure ulcers are one of the most significant harms encountered within our community physical health services.

Ulcer chart 1.jpg
Despite the intense focus pressure ulcers have received over recent years – a national strategy, NICE guidance, CQUIN targets, and our own local reduction plan – evidence emerged that we were still seeing avoidable pressure ulcers in the community. It was against this backdrop the Seaforth and Litherland District Nursing Team started their pressure ulcer improvement journey.

After looking at the findings of a number of investigations, the team introduced two key changes to their practice. The first of these was the ‘pressure ulcer board’ which captures all at risk patients identified via the daily safety huddle – designed to promote awareness and understanding of all relevant patients on the team’s caseload. The second change was the SPUR (Sefton Pressure Ulcer Reminder) which is an aide memoire and visual decision-making support tool. 

Since introducing these changes the team have seen a dramatic reduction in the number of pressure ulcers. Their work is so remarkable they have been shortlisted for the HSJ Patient Safety Awards in the ‘Patient Safety in the Community’ category.

The team will be down in London this month to present their work -  it’s so rewarding to see such innovative practice recognised in this way!

Team Leader Andrea Gore says: "I feel absolutely privileged to work with such a dedicated, innovative and compassionate team." 

Changing the course of history

When things just don't seem right...

You don’t have to spend long in the NHS to realise how much time is devoted to investigating serious incidents, learning the lessons, and reducing the risk of similar incidents happening again. Being involved in the process, important though it is, can be very stressful for staff as well. But how often do you hear stories of serious incidents that never were; incidents narrowly averted because of the prompt actions of staff. And how often do we recognise and celebrate the actions of such staff?
Ashworth hospital provides high secure care and treatment for men who present a grave danger either to themselves or others. It’s perhaps not surprising, therefore, that from time to time this plays out in dangerous acts directed from one patient to another. In fact, managing risk and helping patients to develop more appropriate coping strategies are invariably key aims of the multi-disciplinary team.
A great example of how this works in practice was seen on Keats ward just a few weeks ago.

It all started when experienced ward staff started to sense something was awry. They couldn’t put their finger on it but the atmosphere just “didn’t seem right”.

Using their nursing skills, the staff dialled up their presence in communal areas of the ward, engaging patients proactively in a range of meaningful activities. Sure enough, within a few short hours a blade was handed in to staff, and the soft intelligence starting to accrue suggested there could be other contraband items as well, possibly for use in a targeted assault.
So as not to arouse further suspicion the team went about their duties in a matter of fact way, but made sure senior managers were fully briefed. Overnight plans were drawn up to maintain safety and undertake a full ward search. 

The following morning patients were evacuated to supporting wards and the planned search was expedited, locating a number of other blades. And so, through the prompt actions of staff, and the coordinated support of other departments and ancillary services, the incident was averted and all with minimal disruption to patients.

A post incident review was held the following week with those present reporting how they felt ‘listened to’ in what was clearly a ‘no blame’ meeting. 

The efforts of those involved were also recognised by the Deputy COO, who wrote to all concerned thanking them for their “resilience and skill in adapting to a fluid situation.” Facilities staff, receiving wards and the search team were thanked as well, emphasising the critical importance of “knowing our patients, recognising changes in behaviours and conversations (relational security) and upwardly reporting through the correct processes”.
Knowing Me Knowing You
A ward story...

Taking criticism is not always easy. In fact it can often be human nature to react defensively.

Yet if we are truly to create a Just and Learning culture it’s absolutely vital that we hear and act on such feedback, especially when it comes from service users and their carers.

Irwell is a specialist dementia ward, part of Clock View hospital in Walton. 

Not long after opening, and whilst the ward was still very much in transition from the old to the new, the team there received a complaint from the family of one of their patients, describing how mealtimes on the ward always felt a little bit chaotic. 

Irwell 2.jpgRather than take this personally, however, Irwell's deputy ward manager Louise Edwards saw it as an opportunity to make some real improvements. 

Louise took advice off the division’s dementia lead, spoke to patients and families, and looked at the literature to get a sense of the type of changes they could make.

Since then a whole raft of improvements have been introduced to make the dining experience much more ‘dementia-friendly’. 

Visual prompts have been displayed in the dining room to help orientate patients. Brightly coloured table cloths, plates and place settings have been introduced to help with visual-spatial issues. 

Irwell 3.jpgFood choices on Irwell Ward are now matched more to the needs and preferences of patients, and staff also now take their meals at the same time in order to make the whole process much more of a social experience.

Student nurses have also been involved in projects to raise awareness of specific dietary requirements and preferences, and to ensure more accurate recording on fluid balance charts.

The improvements made were recognised in the recent Care Quality Commission inspection when they observed “…that [Irwell ward] had made significant improvements to the environment in line with best practice guidance”.
This shows just what’s possible with focussed and sustained leadership.
A Star Turn

Staff at the Trust’s Star Unit take great pride in the work they do – delivering high quality person-centred care to people with learning disabilities, autism and complex needs. 

They were naturally hugely disappointed, therefore, when criticised during the recent CQC inspection. Ward manager Kevin Tarpey described that whilst he knew there were issues on the ward, it still came as a massive shock to receive a rating of ‘requires improvement’. 

“We’ve had so much positive feedback from families and carers,” he told us “…and whilst many of the challenges we faced were outside of my control, you can’t help but feel at least partially to blame.”

When summoned to a meeting to discuss the outcome of the inspection Kevin feared the worst, but things did not run as he anticipated. 

Looking back on it now he reflects on how the whole process has actually been really helpful: “I didn’t want to lose the many positives from the report so we pulled the team together and spent some time reminding ourselves of the things we do really well. We also highlighted areas for improvement – both those within our own control and those needing more senior support – and then compiled a service improvement plan. We’re making excellent progress with our own actions, and the Trust has set up a task and finish group to address some of the more strategic issues, including dialogue with commissioners regarding our funding arrangements.”

So whilst there is still work to do, the unit is back on track and has turned the outcome of the inspection into an opportunity to learn and improve.

The upside of going down

Even a cursory glance at the divisional graphs for disciplinary cases in secure and local show a very obvious drop in the number of suspensions and disciplinary cases in the last few months. This is good news all round.

Local division's disciplinary investigations peaked at 31 in May 2016, with suspensions well into double figures every month. The cost, in financial terms as well as personal and moral terms, was enormous in May 2016, with suspensions well into double figures every month.

But then the figures started to go down.

From the second half of 2016, the Trust was considering what it meant to work in a "Just Culture". This was as a result of feedback through our staff survey and comments from staff who said that they often feared to speak up or out when things did not go as expected in the work place.

We started to ask different sorts of questions. We focussed on understanding what had happened and how we can support staff rather than who had done something wrong. It's not easy and we are at the very beginning of our journey. We are quality gathering the learning and we plan to roll this out across other divisions.

What is clear is that staff feel their dignity is higher; they can talk and be listened to rather than there being an automatic presumption that removing one individual would solve all ills.

The most noticeable drop in Local Division – from 30 monthly cases to 22 and then to 17 – came at the end of 2016. 

It is hard to make direct links but in this period the Trust had begun to learn about the new culture. The reduction in new cases is an accurate measure of how we are starting to do things differently and ask different questions to get to a place of understanding. This was the period when the concept went from being on a formal paper to being on everyone's lips.

The case numbers then dropped to six. In Secure, cases peaked at 29 a month in February and March 2016, falling to 9 by November and this financial year started with just a single instance in April 2017.

And the savings, as staff stay in post and remain working means that we continue to benefit from continuity of care and a stable workforce.