Public Inquiry
Mid Staffordshire NHS Foundation Trust Public Inquiry
Status: Completed
Chair: Robert Francis QC
Established: Jun 2010
Report: Feb 2013
Commissioned by: Department of Health and Social Care
Public inquiry into the serious failings in care at Mid Staffordshire NHS Foundation Trust between 2005-2009, where patients were routinely neglected and standards of care were appalling. The Francis Report made 290 recommendations for fundamental culture change to put patients …
Response breakdown
Blanket response: Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.
Evidence & impact
The Mid Staffordshire NHS Foundation Trust Public Inquiry, chaired by Sir Robert Francis QC, examined failures in care at Stafford Hospital between 2005 and 2009. The inquiry's report, published in February 2013, made 290 recommendations aimed at preventing similar failures across the NHS.
The government responded through two documents: 'Patients First and Foremost' in March 2013 and 'Hard Truths: the Journey to Putting Patients First' in November 2013. According to these responses, the government accepted 201 recommendations (69%), accepted in principle 60 recommendations (21%), partially accepted 20 recommendations (7%), and did not accept 9 recommendations (3%).
The government response identified several key reforms, including establishing a new Chief Inspector of Hospitals, strengthening the Care Quality Commission's inspection regime, introducing a statutory duty of candour, and implementing a fit and proper person test for NHS directors. The response also referenced the creation of Health Education England and Healthwatch England as part of wider NHS reforms.
However, the available evidence indicates limited published documentation of progress beyond these initial responses. Of the 290 recommendations, 281 (97%) are recorded as 'Awaiting Action' with no formal progress updates or implementation reviews identified in the public record. This suggests that while the government accepted the majority of Francis's recommendations and announced several high-profile reforms, comprehensive evidence of wider implementation across all recommendations has not been published.
The absence of systematic progress reporting makes it difficult to assess which of the accepted recommendations have been acted upon beyond the headline reforms announced in 2013. No formal implementation review has been identified that would provide comprehensive evidence of progress across all 290 recommendations.
The government responded through two documents: 'Patients First and Foremost' in March 2013 and 'Hard Truths: the Journey to Putting Patients First' in November 2013. According to these responses, the government accepted 201 recommendations (69%), accepted in principle 60 recommendations (21%), partially accepted 20 recommendations (7%), and did not accept 9 recommendations (3%).
The government response identified several key reforms, including establishing a new Chief Inspector of Hospitals, strengthening the Care Quality Commission's inspection regime, introducing a statutory duty of candour, and implementing a fit and proper person test for NHS directors. The response also referenced the creation of Health Education England and Healthwatch England as part of wider NHS reforms.
However, the available evidence indicates limited published documentation of progress beyond these initial responses. Of the 290 recommendations, 281 (97%) are recorded as 'Awaiting Action' with no formal progress updates or implementation reviews identified in the public record. This suggests that while the government accepted the majority of Francis's recommendations and announced several high-profile reforms, comprehensive evidence of wider implementation across all recommendations has not been published.
The absence of systematic progress reporting makes it difficult to assess which of the accepted recommendations have been acted upon beyond the headline reforms announced in 2013. No formal implementation review has been identified that would provide comprehensive evidence of progress across all 290 recommendations.
Reports & milestones
Reports
06 Feb 2013
0 tracked recs
Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Executive Summary
· PDF
06 Feb 2013
290 tracked recs
Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry
· Tracked recommendations
· PDF
06 Feb 2013
0 tracked recs
Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Volume 1
· PDF
06 Feb 2013
0 tracked recs
Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Volume 2
· PDF
06 Feb 2013
0 tracked recs
Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Volume 3
· PDF
Timeline
09 Jun 2010
Inquiry Announced
01 Nov 2010
Inquiry Establish…
06 Feb 2013
Final Report Publ…
Recommendations
| Code | Recommendation | Addressed to | Response | |
|---|---|---|---|---|
| F1 |
It is recommended that: All commissioning, service provision regulatory and ancillary organisations in healthcare should consider the findings and recommendations of this …
|
Department of Health and Social Care | Accepted | View → |
| F2 |
The NHS and all who work for it must adopt and demonstrate a shared culture in which the patient is the priority …
|
NHS | Accepted | View → |
| F3 |
The NHS Constitution should be the first reference point for all NHS patients and staff and should set out the system's common …
|
Department of Health and Social Care | Accepted | View → |
| F4 |
The core values expressed in the NHS Constitution should be given priority of place and the overriding value should be that patients …
|
Department of Health and Social Care | Accepted | View → |
| F5 |
In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that: Staff put patients before themselves; …
|
Department of Health and Social Care | Accepted | View → |
| F6 |
The handbook to the NHS Constitution should be revised to include a much more prominent reference to the NHS values and their …
|
Department of Health and Social Care | Accepted | View → |
| F7 |
All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both …
|
NHS | Accepted in Part | View → |
| F8 |
Contractors providing outsourced services should also be required to abide by these requirements and to ensure that staff employed by them for …
|
Commissioners | Accepted | View → |
| F9 |
The NHS Constitution should include reference to all the relevant professional and managerial codes by which NHS staff are bound, including the …
|
Department of Health and Social Care | Accepted in Part | View → |
| F10 |
The NHS Constitution should incorporate an expectation that staff will follow guidance and comply with standards relevant to their work, such as …
|
Department of Health and Social Care | Accepted in Part | View → |
| F11 |
Healthcare professionals should be prepared to contribute to the development of, and comply with, standard procedures in the areas in which they …
|
Healthcare providers | Accepted | View → |
| F12 |
Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to …
|
Healthcare providers | Accepted | View → |
| F13 |
Standards should be divided into: Fundamental standards of minimum safety and quality – in respect of which non-compliance should not be tolerated. …
|
Department of Health and Social Care | Accepted | View → |
| F14 |
In addition to the fundamental standards of service, the regulations should include generic requirements for a governance system designed to ensure compliance …
|
CQC | Accepted in Part | View → |
| F15 |
All the required elements of governance should be brought together into one comprehensive standard. This should require not only evidence of a …
|
CQC | Accepted in Part | View → |
| F16 |
The Government, through regulation, but after so far as possible achieving consensus between the public and professional representatives, should provide for the …
|
Department of Health and Social Care | Accepted | View → |
| F17 |
The NHS Commissioning Board together with Clinical Commissioning Groups should devise enhanced quality standards designed to drive improvement in the health service. …
|
NHS England | Accepted in Part | View → |
| F18 |
It is essential that professional bodies in which doctors and nurses have confidence are fully involved in the formulation of standards and …
|
Department of Health and Social Care | Accepted | View → |
| F19 |
There should be a single regulator dealing both with corporate governance, financial competence, viability and compliance with patient safety and quality standards …
|
Department of Health and Social Care | Not Accepted | View → |
| F20 |
The Care Quality Commission should be responsible for policing the fundamental standards, through the development of its core outcomes, by specifying the …
|
CQC | Accepted in Part | View → |
| F21 |
The regulator should have a duty to monitor the accuracy of information disseminated by providers and commissioners on compliance with standards and …
|
CQC | Accepted in Part | View → |
| F22 |
The National Institute for Health and Clinical Excellence should be commissioned to formulate standard procedures and practice designed to provide the practical …
|
Accepted in Part | View → | |
| F23 |
The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of …
|
Accepted | View → | |
| F24 |
Compliance with regulatory fundamental standards must be capable so far as possible of being assessed by measures which are understood and accepted …
|
CQC | Accepted | View → |
| F25 |
It should be considered the duty of all specialty professional bodies, ideally together with the National Institute for Health and Clinical Excellence, …
|
Accepted | View → | |
| F26 |
In policing compliance with standards, direct observation of practice, direct interaction with patients, carers and staff, and audit of records should take …
|
CQC | Accepted | View → |
| F27 |
The healthcare systems regulator should promote effective enforcement by: use of a low threshold of suspicion; no tolerance of non-compliance with fundamental …
|
CQC | Accepted | View → |
| F28 |
Zero tolerance: A service incapable of meeting fundamental standards should not be permitted to continue. Breach should result in regulatory consequences attributable …
|
CQC | Accepted | View → |
| F29 |
It should be an offence for death or serious injury to be caused to a patient by a breach of these regulatory …
|
Department of Health and Social Care | Accepted | View → |
| F30 |
The healthcare regulator must be free to require or recommend immediate protective steps where there is reasonable cause to suspect a breach …
|
CQC | Accepted | View → |
| F31 |
Where aware of concerns that patient safety is at risk, Monitor and all other regulators of healthcare providers must have in place …
|
Monitor | Accepted | View → |
| F32 |
Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take …
|
Monitor | Accepted | View → |
| F33 |
Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the …
|
Department of Health and Social Care | Accepted in Part | View → |
| F34 |
Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim …
|
CQC | Accepted in Part | View → |
| F35 |
Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all …
|
CQC | Accepted | View → |
| F36 |
A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in …
|
CQC | Accepted | View → |
| F37 |
Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each …
|
NHS Trusts | Accepted | View → |
| F38 |
The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant …
|
CQC | Accepted | View → |
| F39 |
The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.
|
CQC | Accepted in Part | View → |
| F40 |
It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the …
|
CQC | Accepted | View → |
| F41 |
The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee …
|
CQC | Accepted in Part | View → |
| F42 |
Strategic Health Authorities/their successors should
|
Accepted | View → | |
| F43 |
Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility.
|
CQC | Accepted | View → |
| F44 |
Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was …
|
CQC | Accepted in Part | View → |
| F45 |
The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.
|
CQC | Accepted in Part | View → |
| F46 |
The Quality and Risk Profile should not be regarded as a potential substitute for active regulatory oversight by inspectors. It is important …
|
CQC | Accepted | View → |
| F47 |
The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. …
|
CQC | Accepted | View → |
| F48 |
The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them …
|
CQC | Accepted in Part | View → |
| F49 |
Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring …
|
CQC | Accepted | View → |
| F50 |
The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.
|
CQC | Accepted | View → |
| F51 |
The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of …
|
CQC | Accepted | View → |
| F52 |
The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage …
|
CQC | Accepted | View → |
| F53 |
Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a …
|
Department of Health and Social Care | Accepted | View → |
| F54 |
Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to …
|
CQC | Accepted | View → |
| F55 |
The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and …
|
CQC | Accepted | View → |
| F56 |
The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, …
|
CQC | Accepted | View → |
| F57 |
The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and …
|
CQC | Accepted | View → |
| F58 |
Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there …
|
CQC | Accepted | View → |
| F59 |
Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the …
|
CQC | Accepted in Part | View → |
| F60 |
The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be …
|
Department of Health and Social Care | Accepted in Part | View → |
| F61 |
A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such …
|
Department of Health and Social Care | Not Accepted | View → |
| F62 |
For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into …
|
Monitor | Accepted | View → |
| F63 |
Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.
|
Monitor | Accepted | View → |
| F64 |
The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this …
|
Department of Health and Social Care | Not Accepted | View → |
| F65 |
The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of …
|
Accepted | View → | |
| F66 |
The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to …
|
Department of Health and Social Care | Accepted | View → |
| F67 |
The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for …
|
Accepted | View → | |
| F68 |
No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager …
|
Accepted | View → | |
| F69 |
The assessment criteria for authorisation should include a requirement that applicants demonstrate their ability to consistently meet fundamental patient safety and quality …
|
Monitor | Accepted | View → |
| F70 |
A duty of utmost good faith should be imposed on applicants for foundation trust status to disclose to the regulator any significant …
|
Monitor | Accepted | View → |
| F71 |
The Secretary of State's support for an application should not be given unless he is satisfied that the proposed applicant provides a …
|
Department of Health and Social Care | Accepted | View → |
| F72 |
The assessment for an authorisation of applicant for foundation trust status should include a full physical inspection of its primary clinical areas …
|
Monitor | Accepted | View → |
| F73 |
The Department of Health's regular performance reviews of Monitor (and the Care Quality Commission) should include an examination of its relationship with …
|
Department of Health and Social Care | Accepted | View → |
| F74 |
Monitor and the Care Quality Commission should publish guidance for governors suggesting principles they expect them to follow in recognising their obligation …
|
Monitor | Accepted | View → |
| F75 |
The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the …
|
NHS Trusts | Accepted in Part | View → |
| F76 |
Arrangements must be made to ensure that governors are accountable not just to the immediate membership but to the public at large …
|
NHS Trusts | Accepted | View → |
| F77 |
Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to …
|
NHS England | Accepted | View → |
| F78 |
The Care Quality Commission and Monitor should consider how best to enable governors to have access to a similar advisory facility in …
|
CQC | Accepted | View → |
| F79 |
There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for …
|
CQC | Accepted in Part | View → |
| F80 |
A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be …
|
CQC | Accepted in Part | View → |
| F81 |
Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude …
|
CQC | Accepted | View → |
| F82 |
Provision should be made for regulatory intervention to require the removal or suspension from office after due process of a person whom …
|
CQC | Accepted | View → |
| F83 |
If a "fit and proper person test" is introduced as recommended, Monitor should issue guidance on the principles on which it would …
|
Monitor | Accepted | View → |
| F84 |
Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable …
|
Healthcare providers | Accepted in Part | View → |
| F85 |
Monitor and the Care Quality Commission should produce guidance to NHS and foundation trusts on procedures to be followed in the event …
|
CQC | Accepted | View → |
| F86 |
A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of …
|
NHS Trusts | Accepted | View → |
| F87 |
The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should …
|
Department of Health and Social Care | Accepted in Part | View → |
| F88 |
The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators …
|
Accepted in Part | View → | |
| F89 |
Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and …
|
Healthcare providers | Accepted in Part | View → |
| F90 |
In order to determine whether a case is so serious, either in terms of the breach of safety requirements or the consequences …
|
Accepted | View → | |
| F91 |
The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not …
|
Department of Health and Social Care | Accepted in Part | View → |
| F92 |
The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.
|
Accepted | View → | |
| F93 |
The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, …
|
Accepted in Part | View → | |
| F94 |
As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to …
|
Accepted | View → | |
| F95 |
As the interests of patient safety should prevail over the narrow litigation interest under which confidentiality or even privilege might be claimed …
|
Accepted | View → | |
| F96 |
The NHS Litigation Authority should make more prominent in its publicity an explanation comprehensible to the general public of the limitations of …
|
Accepted | View → | |
| F97 |
The National Patient Safety Agency's resources need to be well protected and defined. Consideration should be given to the transfer of this …
|
NHS England | Accepted in Part | View → |
| F98 |
Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm …
|
NHS England | Accepted in Part | View → |
| F99 |
The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative …
|
NHS England | Accepted in Part | View → |
| F100 |
Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt …
|
CQC | Accepted in Part | View → |
| F101 |
While it may be impracticable for the National Patient Safety Agency or its successor to have its own team of inspectors, it …
|
NHS England | Accepted | View → |
| F102 |
Data held by the National Patient Safety Agency or its successor should be open to analysis for a particular purpose, or others …
|
NHS England | Accepted | View → |
| F103 |
The National Patient Safety Agency or its successor should regularly share information with Monitor.
|
NHS England | Accepted | View → |
| F104 |
The Care Quality Commission should be enabled to exploit the potential of the safety information obtained by the National Patient Safety Agency …
|
CQC | Accepted | View → |
| F105 |
Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality …
|
NHS England | Accepted | View → |
| F106 |
The Health Protection Agency and its successor, should coordinate the collection, analysis and publication of information on each provider's performance in relation …
|
Accepted | View → | |
| F107 |
If the Health Protection Agency or its successor, or the relevant local director of public health or equivalent official, becomes concerned that …
|
Accepted | View → | |
| F108 |
Public Health England should review the support and training that health protection staff can offer to local authorities and other agencies in …
|
Accepted | View → | |
| F109 |
Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, …
|
Healthcare providers | Accepted | View → |
| F110 |
Actual or intended litigation should not be a barrier to the processing or investigation of a complaint at any level. It may …
|
Healthcare providers | Accepted | View → |
| F111 |
Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be …
|
Healthcare providers | Accepted | View → |
| F112 |
Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of …
|
Healthcare providers | Accepted | View → |
| F113 |
The recommendations and standards suggested in the Patients Association's peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be …
|
NHS | Accepted | View → |
| F114 |
Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
|
Healthcare providers | Accepted | View → |
| F115 |
Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint …
|
Healthcare providers | Accepted in Part | View → |
| F116 |
Where meetings are held between complainants and trust representatives or investigators as part of the complaints process, advocates and advice should be …
|
Healthcare providers | Accepted | View → |
| F117 |
A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases.
|
Department of Health and Social Care | Accepted in Part | View → |
| F118 |
Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's …
|
Healthcare providers | Accepted in Part | View → |
| F119 |
Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in …
|
Healthcare providers | Accepted | View → |
| F120 |
Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on …
|
Commissioners | Accepted in Part | View → |
| F121 |
The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should …
|
CQC | Accepted | View → |
| F122 |
Large-scale failures of clinical service are likely to have in common a need for: Provision of prompt advice, counselling and support to …
|
Accepted in Part | View → | |
| F123 |
GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should …
|
Accepted | View → | |
| F124 |
The commissioner is entitled to and should, wherever it is possible to do so, apply a fundamental safety and quality standard in …
|
Commissioners | Accepted in Part | View → |
| F125 |
In addition to their duties with regard to the fundamental standards, commissioners should be enabled to promote improvement by requiring compliance with …
|
Commissioners | Accepted | View → |
| F126 |
The NHS Commissioning Board and local commissioners should develop and oversee a code of practice for managing organisational transitions, to ensure the …
|
NHS England | Accepted | View → |
| F127 |
The NHS Commissioning Board and local commissioners must be provided with the infrastructure and the support necessary to enable a proper scrutiny …
|
NHS England | Accepted | View → |
| F128 |
Commissioners must have access to the wide range of experience and resources necessary to undertake a highly complex and technical task, including …
|
Commissioners | Accepted | View → |
| F129 |
In selecting indicators and means of measuring compliance, the principal focus of commissioners should be on what is reasonably necessary to safeguard …
|
Commissioners | Accepted | View → |
| F130 |
Commissioners – not providers – should decide what they want to be provided. They need to take into account what can be …
|
Commissioners | Accepted | View → |
| F131 |
Commissioners need, wherever possible, to identify and make available alternative sources of provision. This may mean that commissioning has to be undertaken …
|
Commissioners | Accepted | View → |
| F132 |
Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis during the contract period: Such …
|
Commissioners | Accepted | View → |
| F133 |
Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to …
|
Commissioners | Accepted in Part | View → |
| F134 |
Consideration should be given to whether commissioners should be given responsibility for commissioning patients' advocates and support services for complaints against providers.
|
Commissioners | Accepted | View → |
| F135 |
Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public …
|
Commissioners | Accepted in Part | View → |
| F136 |
Commissioners need to be recognisable public bodies, visibly acting on behalf of the public they serve and with a sufficient infrastructure of …
|
Commissioners | Accepted | View → |
| F137 |
Commissioners should have powers of intervention where substandard or unsafe services are being provided, including requiring the substitution of staff or other …
|
Commissioners | Not Accepted | View → |
| F138 |
Commissioners should have contingency plans with regard to the protection of patients from harm, where it is found that they are at …
|
Commissioners | Accepted | View → |
| F139 |
The first priority for any organisation charged with responsibility for performance management of a healthcare provider should be ensuring that fundamental patient …
|
NHS England | Accepted | View → |
| F140 |
Where concerns are raised that such standards are not being complied with, a performance management organisation should share, wherever possible, all relevant …
|
NHS England | Accepted | View → |
| F141 |
Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and …
|
NHS England | Accepted in Part | View → |
| F142 |
For an organisation to be effective in performance management, there must exist unambiguous lines of referral and information flows, so that the …
|
NHS England | Accepted | View → |
| F143 |
Metrics need to be established which are relevant to the quality of care and patient safety across the service, to allow norms …
|
NHS England | Accepted | View → |
| F144 |
The NHS Commissioning Board should ensure the development of metrics on quality and outcomes of care for use by commissioners in managing …
|
NHS England | Accepted | View → |
| F145 |
There should be a consistent basic structure for Local Healthwatch throughout the country, in accordance with the principles set out in Chapter …
|
Department of Health and Social Care | Not Accepted | View → |
| F146 |
Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to …
|
Accepted in Part | View → | |
| F147 |
Guidance should be given to promote the coordination and cooperation between Local Healthwatch, Health and Wellbeing Boards, and local government scrutiny committees.
|
Department of Health and Social Care | Accepted | View → |
| F148 |
The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well …
|
Accepted | View → | |
| F149 |
Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and …
|
Accepted | View → | |
| F150 |
Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or …
|
Accepted in Part | View → | |
| F151 |
MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They …
|
Parliament | Accepted in Part | View → |
| F152 |
Any organisation which in the course of a review, inspection or other performance of its duties, identifies concerns potentially relevant to the …
|
Healthcare providers | Accepted | View → |
| F153 |
The Secretary of State should by statutory instrument specify all medical education and training regulators as relevant bodies for the purpose of …
|
Department of Health and Social Care | Accepted in Part | View → |
| F154 |
The Care Quality Commission and Monitor should develop practices and procedures with training regulators and bodies responsible for the commissioning and oversight …
|
CQC | Accepted | View → |
| F155 |
The General Medical Council should set out a standard requirement for routine visits to each local education provider, and programme in accordance …
|
GMC | Accepted | View → |
| F156 |
The system for approving and accrediting training placement providers and programmes should be configured to apply the principles set out above.
|
GMC | Accepted | View → |
| F157 |
The General Medical Council should set out a clear statement of what matters; deaneries are required to report to the General Medical …
|
GMC | Accepted | View → |
| F158 |
The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from …
|
GMC | Accepted | View → |
| F159 |
Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards …
|
GMC | Accepted | View → |
| F160 |
Proactive steps need to be taken to encourage openness on the part of trainees and to protect them from any adverse consequences …
|
GMC | Accepted | View → |
| F161 |
Training visits should make an important contribution to the protection of patients: Obtaining information directly from trainees should remain a valuable source …
|
GMC | Accepted | View → |
| F162 |
The General Medical Council should in the course of its review of its standards and regulatory process ensure that the system of …
|
GMC | Accepted | View → |
| F163 |
The General Medical Council's system of reviewing the acceptability of the provision of training by healthcare providers must include a review of …
|
GMC | Accepted | View → |
| F164 |
The Department of Health and the General Medical Council should review whether the resources available for regulating Approved Practice Setting are adequate …
|
GMC | Accepted in Part | View → |
| F165 |
The General Medical Council should immediately review its approved practice settings criteria with a view to recognition of the priority to be …
|
GMC | Accepted in Part | View → |
| F166 |
The General Medical Council should in consultation with patient interest groups and the public immediately review its procedures for assuring compliance with …
|
GMC | Accepted in Part | View → |
| F167 |
The Department of Health and the General Medical Council should review the powers available to the General Medical Council in support of …
|
GMC | Accepted in Part | View → |
| F168 |
The Department of Health and the General Medical Council should consider making the necessary statutory (and regulatory changes) to incorporate the approved …
|
Department of Health and Social Care | Accepted in Part | View → |
| F169 |
The Department of Health, through the National Quality Board, should ensure that procedures are put in place for facilitating the identification of …
|
Department of Health and Social Care | Accepted in Part | View → |
| F170 |
Health Education England should have a medically qualified director of medical education and a lay patient representative on its board.
|
NHS England Health Education England | Accepted | View → |
| F171 |
All Local Education and Training Boards should have a post of medically qualified postgraduate dean responsible for all aspects of postgraduate medical …
|
NHS England Health Education England | Accepted | View → |
| F172 |
The Government should consider urgently the introduction of a common requirement of proficiency in communication in the English language with patients and …
|
Department of Health and Social Care | Accepted | View → |
| F173 |
Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the …
|
Healthcare providers | Accepted | View → |
| F174 |
Where death or serious harm has been or may have been caused to a patient by an act or omission of the …
|
Healthcare providers | Accepted | View → |
| F175 |
Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a …
|
Healthcare providers | Accepted | View → |
| F176 |
Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not …
|
Healthcare providers | Accepted | View → |
| F177 |
Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.
|
Healthcare providers | Accepted | View → |
| F178 |
The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and …
|
Department of Health and Social Care | Accepted in Part | View → |
| F179 |
"Gagging clauses" or non disparagement clauses should be prohibited in the policies and contracts of all healthcare organisations, regulators and commissioners; insofar …
|
Department of Health and Social Care | Accepted | View → |
| F180 |
Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the …
|
Healthcare providers | Accepted | View → |
| F181 |
A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or …
|
Department of Health and Social Care | Accepted in Part | View → |
| F182 |
There should be a statutory duty on all directors of healthcare organisations to be truthful in any information given to a healthcare …
|
Department of Health and Social Care | Accepted | View → |
| F183 |
It should be made a criminal offence for any registered medical practitioner, or nurse, or allied health professional or director of an …
|
Department of Health and Social Care | Not Accepted | View → |
| F184 |
Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute …
|
CQC | Accepted | View → |
| F185 |
There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in …
|
NMC | Accepted | View → |
| F186 |
Nursing training should be reviewed so that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all …
|
NMC | Accepted | View → |
| F187 |
There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on …
|
NMC | Accepted | View → |
| F188 |
The Nursing and Midwifery Council, working with universities, should consider the introduction of an aptitude test to be undertaken by aspirant registered …
|
NMC | Accepted in Part | View → |
| F189 |
The Nursing and Midwifery Council and other professional and academic bodies should work towards a common qualification assessment/examination.
|
NMC | Accepted in Part | View → |
| F190 |
There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver …
|
NMC | Accepted in Part | View → |
| F191 |
Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess candidates' values, attitudes and behaviours towards the well-being of patients and …
|
Healthcare providers | Accepted | View → |
| F192 |
The Department of Health and Nursing and Midwifery Council should introduce the concept of a Responsible Officer for nursing, appointed by and …
|
NMC | Accepted in Part | View → |
| F193 |
Without introducing a revalidation scheme immediately, the Nursing and Midwifery Council should introduce common minimum standards for appraisal and support with which …
|
NMC | Accepted in Part | View → |
| F194 |
As part of a mandatory annual performance appraisal, each Nurse, regardless of workplace setting, should be required to demonstrate in their annual …
|
NMC | Accepted in Part | View → |
| F195 |
Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up, except in emergencies as …
|
Healthcare providers | Accepted in Part | View → |
| F196 |
The Knowledge and Skills Framework should be reviewed with a view to giving explicit recognition to nurses' demonstrations of commitment to patient …
|
Department of Health and Social Care | Accepted | View → |
| F197 |
Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse …
|
NHS | Accepted in Part | View → |
| F198 |
Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing …
|
Healthcare providers | Accepted | View → |
| F199 |
Each patient should be allocated for each shift a named key nurse responsible for coordinating the provision of the care needs for …
|
Healthcare providers | Accepted | View → |
| F200 |
Consideration should be given to the creation of a status of Registered Older Person's Nurse.
|
NMC | Accepted in Part | View → |
| F201 |
The Royal College of Nursing should consider whether it should formally divide its "Royal College" functions and its employee representative/trade union functions …
|
Accepted | View → | |
| F202 |
Recognition of the importance of nursing representation at provider level should be given by ensuring that adequate time is allowed for staff …
|
Healthcare providers | Accepted | View → |
| F203 |
A forum for all directors of nursing from both NHS and independent sector organisations should be formed to provide a means of …
|
Department of Health and Social Care | Accepted | View → |
| F204 |
All healthcare providers and commissioning organisations should be required to have at least one executive director who is a registered nurse, and …
|
Healthcare providers | Accepted in Part | View → |
| F205 |
Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact …
|
Commissioners | Accepted in Part | View → |
| F206 |
The effectiveness of the newly positioned office of Chief Nursing Officer should be kept under review to ensure the maintenance of a …
|
Department of Health and Social Care | Accepted | View → |
| F207 |
There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title.
|
Department of Health and Social Care | Accepted in Part | View → |
| F208 |
Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that a healthcare support worker is easily …
|
Commissioners | Accepted in Part | View → |
| F209 |
A registration system should be created under which no unregistered person should be permitted to provide for reward direct physical care to …
|
Department of Health and Social Care | Not Accepted | View → |
| F210 |
There should be a national code of conduct for healthcare support workers.
|
Department of Health and Social Care | Accepted | View → |
| F211 |
There should be a common set of national standards for the education and training of healthcare support workers.
|
Department of Health and Social Care | Accepted | View → |
| F212 |
The code of conduct, education and training standards and requirements for registration for healthcare support workers should be prepared and maintained by …
|
NMC | Not Accepted | View → |
| F213 |
Until such time as the Nursing and Midwifery Council is charged with the recommended regulatory responsibilities, the Department of Health should institute …
|
Department of Health and Social Care | Not Accepted | View → |
| F214 |
A leadership staff college or training system, whether centralised or regional, should be created to: provide common professional training in management and …
|
Accepted | View → | |
| F215 |
A common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to …
|
Department of Health and Social Care | Accepted | View → |
| F216 |
The leadership framework should be improved by increasing the emphasis given to patient safety in the thinking of all in the health …
|
Accepted | View → | |
| F217 |
A list should be drawn up of all the qualities generally considered necessary for a good and effective leader. This in turn …
|
Accepted in Part | View → | |
| F218 |
Serious non-compliance with the code, and in particular, non-compliance leading to actual or potential harm to patients, should render board-level leaders and …
|
CQC | Accepted | View → |
| F219 |
An alternative option to enforcing compliance with a management code of conduct, with the risk of disqualification, would be to set up …
|
Department of Health and Social Care | Accepted in Part | View → |
| F220 |
A training facility could provide the route through which an accreditation scheme could be organised. Although this might be a voluntary scheme, …
|
Accepted in Part | View → | |
| F221 |
Consideration should be given to ensuring that there is regulatory oversight of the competence and compliance with appropriate standards by the boards …
|
CQC | Accepted | View → |
| F222 |
The General Medical Council should have a clear policy about the circumstances in which a generic complaint or report ought to be …
|
GMC | Accepted | View → |
| F223 |
If the General Medical Council is to be effective in looking into generic complaints and information it will probably need either greater …
|
GMC | Accepted in Part | View → |
| F224 |
Steps must be taken to systematise the exchange of information between the Royal Colleges and the General Medical Council, and to issue …
|
GMC | Accepted | View → |
| F225 |
The General Medical Council should have regard to the possibility of commissioning peer reviews pursuant to section 35 of the Medical Act …
|
GMC | Accepted | View → |
| F226 |
To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council …
|
NMC | Accepted in Part | View → |
| F227 |
The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where …
|
NMC | Accepted in Part | View → |
| F228 |
It is of concern that the administration of the Nursing and Midwifery Council, which has not been examined by this Inquiry, is …
|
NMC | Accepted | View → |
| F229 |
It is highly desirable that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical …
|
NMC | Accepted | View → |
| F230 |
The profile of the Nursing and Midwifery Council needs to be raised with the public, who are the prime and most valuable …
|
NMC | Accepted | View → |
| F231 |
It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action …
|
NMC | Accepted | View → |
| F232 |
The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to …
|
NMC | Accepted | View → |
| F233 |
While both the General Medical Council and the Nursing and Midwifery Council have highly informative internet sites, both need to ensure that …
|
GMC | Accepted | View → |
| F234 |
Both the General Medical Council and Nursing and Midwifery Council must develop closer working relationships with the Care Quality Commission – in …
|
GMC | Accepted | View → |
| F235 |
The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under …
|
Accepted in Part | View → | |
| F236 |
Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient's case, so …
|
Healthcare providers | Accepted | View → |
| F237 |
There needs to be effective teamwork between all the different disciplines and services that together provide the collective care often required by …
|
Healthcare providers | Accepted | View → |
| F238 |
Regular interaction and engagement between nurses and patients and those close to them should be systematised through regular ward rounds: All staff …
|
Healthcare providers | Accepted | View → |
| F239 |
The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be …
|
Healthcare providers | Accepted | View → |
| F240 |
All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged …
|
Healthcare providers | Accepted | View → |
| F241 |
The arrangements and best practice for providing food and drink to elderly patients require constant review, monitoring and implementation.
|
Healthcare providers | Accepted | View → |
| F242 |
In the absence of automatic checking and prompting, the process of the administration of medication needs to be overseen by the nurse …
|
Healthcare providers | Accepted | View → |
| F243 |
The recording of routine observations on the ward should, where possible, be done automatically as they are taken, with results being immediately …
|
Healthcare providers | Accepted | View → |
| F244 |
There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. …
|
NHS | Accepted | View → |
| F245 |
Each provider organisation should have a board level member with responsibility for information.
|
Healthcare providers | Accepted in Part | View → |
| F246 |
Department of Health/the NHS Commissioning Board/regulators should ensure that provider organisations publish in their annual quality accounts information in a common form …
|
Department of Health and Social Care | Accepted | View → |
| F247 |
Healthcare providers should be required to lodge their quality accounts with all organisations commissioning services from them, Local Healthwatch, and all systems …
|
Healthcare providers | Accepted | View → |
| F248 |
Healthcare providers should be required to have their quality accounts independently audited. Auditors should be given a wider remit enabling them to …
|
Healthcare providers | Accepted | View → |
| F249 |
Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying …
|
Healthcare providers | Accepted in Part | View → |
| F250 |
It should be a criminal offence for a director to sign a declaration of belief that the contents of a quality account …
|
Department of Health and Social Care | Accepted in Part | View → |
| F251 |
The Care Quality Commission and/or Monitor should keep the accuracy, fairness and balance of quality accounts under review and should be enabled …
|
CQC | Accepted in Part | View → |
| F252 |
It is important that the appropriate steps are taken to enable properly anonymised data to be used for managerial and regulatory purposes.
|
Department of Health and Social Care | Accepted | View → |
| F253 |
The information behind the quality and risk profile – as well as the ratings and methodology – should be placed in the …
|
CQC | Accepted | View → |
| F254 |
While there are likely to be many different gateways offered through which patient and public comments can be made, to avoid confusion, …
|
NHS England | Accepted | View → |
| F255 |
Results and analysis of patient feedback including qualitative information need to be made available to all stakeholders in as near "real time" …
|
NHS England | Accepted | View → |
| F256 |
A proactive system for following up patients shortly after discharge would not only be good "customer service", it would probably provide a …
|
Healthcare providers | Accepted | View → |
| F257 |
The Information Centre should be tasked with the independent collection, analysis, publication and oversight of healthcare information in England, or, with the …
|
Accepted in Part | View → | |
| F258 |
The Information Centre should continue to develop and maintain learning, standards and consensus with regard to information methodologies, with particular reference to …
|
Accepted | View → | |
| F259 |
The Information Centre, in consultation with the Department of Health, the NHS Commissioning Board and the Parliamentary and Health Service Ombudsman, should …
|
Accepted | View → | |
| F260 |
The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in …
|
Accepted in Part | View → | |
| F261 |
The Information Centre should be enabled to undertake more detailed statistical analysis of its own than currently appears to be the case.
|
Accepted | View → | |
| F262 |
All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and maintain systems which give them: Effective real-time information on …
|
Healthcare providers | Accepted | View → |
| F263 |
It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for …
|
Healthcare providers | Accepted | View → |
| F264 |
In the case of each specialty, a programme of development for statistics on the efficacy of treatment should be prepared, published, and …
|
Royal Colleges | Accepted | View → |
| F265 |
The Department of Health, the Information Centre and the Care Quality Commission should engage with each representative specialty organisation in order to …
|
Department of Health and Social Care | Accepted | View → |
| F266 |
In designing the methodology for such statistics and their presentation, the Department of Health, the Information Centre, the Care Quality Commission and …
|
Department of Health and Social Care | Accepted | View → |
| F267 |
All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care …
|
Healthcare providers | Accepted | View → |
| F268 |
Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant …
|
Healthcare providers | Accepted | View → |
| F269 |
The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This …
|
Healthcare providers | Accepted | View → |
| F270 |
There is a need for a review by the Department of Health, the Information Centre and the UK Statistics Authority of the …
|
Department of Health and Social Care | Accepted | View → |
| F271 |
To the extent that summary hospital-level mortality indicators are not already recognised as national or official statistics, the Department of Health and …
|
Department of Health and Social Care | Accepted | View → |
| F272 |
There is a demonstrable need for an accreditation system to be available for healthcare-relevant statistical methodologies. The power to create an accreditation …
|
Department of Health and Social Care | Accepted | View → |
| F273 |
The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable …
|
Healthcare providers | Accepted in Part | View → |
| F274 |
There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of …
|
Department of Health and Social Care | Accepted | View → |
| F275 |
It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.
|
Department of Health and Social Care | Accepted in Part | View → |
| F276 |
Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the …
|
Department of Health and Social Care | Accepted | View → |
| F277 |
National guidance should set out standard methodologies for approaching the certification of the cause of death to ensure, so far as possible, …
|
Department of Health and Social Care | Accepted | View → |
| F278 |
It should be a routine part of an independent medical examiners's role to seek out and consider any serious untoward incidents or …
|
Healthcare providers | Accepted | View → |
| F279 |
So far as is practicable, the responsibility for certifying the cause of death should be undertaken and fulfilled by the consultant, or …
|
Healthcare providers | Accepted | View → |
| F280 |
Both the bereaved family and the certifying doctor should be asked whether they have any concerns about the death or the circumstances …
|
Healthcare providers | Accepted | View → |
| F281 |
It is important that independent medical examiners and any others having to approach families for this purpose have careful training in how …
|
Department of Health and Social Care | Accepted | View → |
| F282 |
Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.
|
Coroners | Accepted | View → |
| F283 |
Guidance should be developed for coroners' offices about whom to approach in gathering information about whether to hold an inquest into the …
|
Accepted | View → | |
| F284 |
The Lord Chancellor should issue guidance as to the criteria to be adopted in the appointment of assistant deputy coroners.
|
Accepted | View → | |
| F285 |
The Chief Coroner should issue guidance on how to avoid the appearance of bias when assistant deputy coroners are associated with a …
|
Accepted | View → | |
| F286 |
Impact and risk assessments should be made public, and debated publicly, before a proposal for any major structural change to the healthcare …
|
Department of Health and Social Care | Accepted | View → |
| F287 |
The Department of Health should together with healthcare systems regulators take the lead in developing through obtaining consensus between the public and …
|
Department of Health and Social Care | Accepted | View → |
| F288 |
The Department of Health should ensure that there is senior clinical involvement in all policy decisions which may impact on patient safety …
|
Department of Health and Social Care | Accepted | View → |
| F289 |
Department of Health officials need to connect more to the NHS by visits, and most importantly by personal contact with those who …
|
Department of Health and Social Care | Accepted | View → |
| F290 |
The Department of Health should promote a shared positive culture by setting an example in its statements by being open about deficiencies, …
|
Department of Health and Social Care | Accepted | View → |