Part of our role is to help improve public services. So if we find an organisation has not put something right that we find went wrong, we will usually recommend it makes improvements to its way of working.
This will often include asking you to prepare an action plan to address the failings we found. This is to make sure the same failings do not happen again and has to be done within an agreed time frame.
When we ask you make improvements to the way you work, we will not usually be specific about what we expect you to do. This is because you are best placed to know how to make changes in your organisation. We suggest that when you develop your action plan you consider involving the person who raised the complaint as much as possible, and keep them informed until the changes are made.
How to write your action plan
We do not ask you to use a specific format to write your action plan. However, we have produced an action plan template (Word 764KB) to show you how it could be structured.
We expect to see you have fully explained:
- the specific actions you have taken or planned to take to prevent each of the failings (including complaint handling) from happening again
- the names of the person or team responsible for completing each action
- when the actions will begin, and when they will be complete
- how you will make sure that the actions comply with relevant professional or appropriate standards;
- how and when you will review the actions to make sure they have been successfully completed
- how you will monitor and audit the actions you have made to make sure any improvements to your service are maintained
- how you will measure the impact of those actions.
Action plan checklist
- Does the plan address all the failings we identified in our investigation report, including any complaint handling issues?
- Are you satisfied the actions in the plan are sufficient to prevent these failings from happening again?
- Does the plan explain who will take responsibility for each of the actions, when the actions will begin, and when they will be completed?
- Have you considered involving the person who raised the complaint, and how you will include them in the action plan process?
- Have you included any evidence to show the actions that you have already taken?
- Are the actions set out in the plan fully compliant with any relevant professional or appropriate standards? Where you have referenced any standards, please say what they are.
- Have you set a date by which you will review the actions?
- Have you sent a copy of the plan to all the people and/or organisations we have listed in our final investigation report?
- Have you included a copy of our final report with the action plan you sent to the regulator?
- Have you made arrangements for updates on progress to be sent to all the people and/or organisations we have listed in our final investigation report?
Download a Word version of the checklist (Word 763KB).
Sending us your action plan
If you think that you will not be able to prepare an action plan in the timescale that we suggested, please let us know as soon as possible. We may be able to agree a different timescale. If you have completed any of the actions, please include supporting evidence for this when you send the plan to us.
When we receive your action plan we will carefully review it, and if we are not happy with it, or we do not receive it within the time that we have agreed with you, we may consider taking further action.
Once we are happy with an action plan, we will ask you to confirm that you will send it to all the people and organisations we have listed in our final investigation report.
Sending your action plan to a regulator
We may ask you to send a copy of your action plan to a regulator, such as the Care Quality Commission or NHS Improvement. When you contact the regulator please explain that following our investigation, we have asked you to send it a copy of your action plan and include a copy of our investigation report at the same time. When you send the documents, please bear in mind your own data protection responsibilities.
This may include anonymising our final report and removing any personal details from the action plan before you send it. It would also be helpful to include your organisation’s name and address separately on the plan.
You can contact the regulator by email, and we will tell you the correct email address in the covering letter that we send out with our final investigation report.
The commissioning organisations and regulators will monitor how you implement the action plan and how effective it is.
If you are a member of a medical defence organisation (MDO), then they may be able to offer further help.
If you have any feedback about this information, please email: email@example.com