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Supporting Guidance Standard 6.3

Health and Care Standards

Supporting Guidance

Standard 6.3 Listening and Learning from Feedback


What is the Standard about?

The need for all NHS organisations to listen to service users, their carers and families about their experience of care received.  It is about what it is actually like to be a service user in the NHS and how that first-hand experience of care can be improved. As well as clinical interventions it includes access, responsiveness, choice, physical environment and more.  It is important that as well as listening to patients, NHS organisations use the information they provide to make improvements to their services.  Boards of NHS organisations need to be assured that their organisation is meeting the needs of service users and using information about their experience to improve services. 

This standard is about responding effectively and dealing fairly, openly and proactively with ‘concerns’ and demonstrating that lessons have been learned. This includes providing the right support to patients, service users, carers and staff throughout the process.


Who is it for?

NHS organisations and services, patients, service users and carers in all healthcare settings.

In relation to the standard criteria (in bold) the following key questions need to be considered:

Health services and boards demonstrate how they are responding to user experience to improve services.

  • How do you obtain service user experience feedback?
  • Do you use all four quadrants of the Service User Experience Framework to ensure you are getting the full range of feedback?
  • Do you use a variety of methods to obtain feedback eg online, paper, social media?
  • Do you use compliments to obtain feedback on what service users like?  Are you able to use this information to make improvements in other areas?
  • How do you analyse the feedback received?
  • Do you triangulate the service user experience feedback with information on concerns and serious incidents?
  • How do you inform your Board of the results of the analysis? 
  • Are you able to identify improvements to your services based on the feedback received?
  • Are you able to make those improvements to your services?
  • Do you inform your Board of the improvements made as a result of service user feedback?
  • Do you inform service users of improvements made based on feedback received?  E.g. ‘You said - we did’.
  • Do you inform service users of improvements through a variety of methods?  E.g. website, posters, social media.
  • Do you include service user experience feedback in your Annual Quality Statement?
  • How do you capture key issues, both positive and negative raised by people living with dementia, cognitive impairment, sensory loss and their carers?  How do you feedback the specific actions taken to address negative issues?
  • How do you ensure service users are able to provide feedback in their preferred language?

Partners are engaged in supporting and enabling people to be involved in the design planning and delivery of services.

  • How do you engage with service users and the public?
  • Do you have patient focus groups or patient participation groups?
  • Do you involve service users and the public in the planning and delivery of services?
  • How do you communicate your need for engagement on service changes with the public?
  • Do you hold regular service user engagement events?  Are they organised at a suitable time and place for your audience?
  • How does your organisation comply with the Older People’s Commissioner Wales’ Guidance – Best Practice Guidance for Engagement and Consultation with older people on Changes to Health Services in Wales
  • How do you ensure you are communicating / engaging with service users in their language of choice?

The patient’s and carer's voice is heeded by health services and boards, including through the use of patient stories.

  • Are both good and bad patient stories told at Board meetings?
  • Are patient stories told at Clinical Directorate and staff meetings?
  • Are you able to demonstrate service improvements as a result of patient stories
  • How do you communicate service improvements made as a result of patient stories?
  • Do you use patient stories in your Annual Quality Statement?

Feedback is captured, published and acted upon in a way that provides an ongoing and continuous view of performance and demonstrates learning and improvement.

  • Do you publish the analysis of service user experience feedback? 
  • Is the information provided in a plain English/Welsh format?
  • Does it provide examples of where service user feedback has led to service improvements? 
  • Is the publication easy to find on your website?

Service delivery improvement for all people is captured and demonstrated which includes as a consequence meeting statutory responsibilities for children and young people, equality and diversity, and the Welsh language.

  • Do you collect equality and diversity information when requesting service user experience feedback?
  • Do you liaise with your equality and diversity leads to ensure you are targeting the correct audience? 
  • Do you analyse the equality and diversity information to ensure you are reaching the correct target audience?

It is clear how data reported in national surveys and audits are used and applied.

  • Are you transparent in the publication of data on national surveys and audit?
  • Is the information explained in plain English/Welsh?

There are processes in place that assure a good experience for people which include:

  • assessing and evaluating service user experience, especially for those who are vulnerable;
  • Provision for people who are less able to speak for themselves
  • delivering and measuring improvement
  • using patient feedback to influence/drive changes to service provision and delivery
  • recognising the spiritual, pastoral and religious dimension of care
  • How do you ensure that all staff who work directly with patients are trained in an understanding of the holistic model of care i.e. the bio-pyscho-social-spiritual model and spiritual/pastoral issues and ensure that all patients are asked about their spiritual/religious beliefs and pastoral needs?
  • How does your organisation ensure compliance with the legislative requirements of the Mental Health Measure (Wales) 2010 Code of Practice:
    • to assess and where appropriate address the spiritual needs of patients accessing services under Part 2 of the Mental Health Measure
    • to ensure there is adequate chaplaincy resources available to mental health services
  • How do you ensure that any personal, spiritual/religious, pastoral needs expressed are acted upon?
  • How are patients informed of the availability of, and offered chaplaincy services?
  • How does your organisation ensure that the directory of relevant faith and third sector organisations is kept up to date and available to staff on the frontline?
  • Does your organisation ensure that spiritual/religious/pastoral care provision is embedded within the care pathway?
  • How do you ensure that patients are referred to the chaplaincy service?
  • Is there documented evidence that the patient's spiritual, pastoral, religious and cultural needs have been assessed and discussed with the patient or advocate?
  • Do your patient experience evaluations routinely include questions relating to spiritual/religious/pastoral needs?

There is compliance with legislation and guidance to deal with concerns, incidents, near misses, and claims as set out in the “Putting Things Right” arrangements.

  • How do you respond to the findings of the Welsh Risk Pool Services’ Concerns and Compensation, Claims Management annual assessment?
  • How do you deal with non-compliance with Putting Things Right (PTR) arrangements?
  • What board level involvement/oversight is there for Putting Things Right?
  • Do you publish your annual PTR report? 
  • Does it meet the requirements of the PTR regulations?

Concerns are reported, acted upon and responded to in an appropriate and timely manner and are handled and investigated openly, effectively and by those appropriately skilled to do so.

  • Are staff empowered to ‘nip concerns in the bud’? 
  • Have they been trained to assist service users, carers and families with ‘nipping concerns in the bud’?
  • How do you ensure that your incident reporting, handling and investigating are effective?
  • Are incidents and near misses reported to National Reporting and Learning System (NRLS)?
  • Are the appropriate staff trained in Root Cause Analysis (RCA)?
  • How do you comply with the timely reporting requirements of external bodies, e.g. Coroners, Ombudsman and HSE, etc?

Patients, service users and their carers are offered support including advocacy and where appropriate redress.

  • How do you work with and support staff involved in a concern?
  • How do you maintain communication with staff throughout the management of the concern?
  • Do you maintain communication with the complainant throughout the management of the concern?
  • How is independent advocacy made available to patients, service users and carers?
  • How do you feedback/share the learning from a concern with staff?
  • How do you feedback learning from a concern with service users?
  • Do you work with your local Community Health Council to ensure advocacy services are provided?

Health services are open and honest with people when something goes wrong with their care and treatment.

  • How do you ensure staff adhere to the Being Open policy?
  • Have staff been trained in Being Open?

Appropriate support is provided to health staff and learning and services improve through sharing lessons from local and national reviews.

  • How do you use national clinical audits, other national reviews and HIW reports to identify areas for improvement?
  • How do you use NRLS data to identify areas of improvement?
  • How do you use NRLS data to triangulate with other data on concerns to identify themes and trends?


Legislation and Guidance