Inquiries · Recommendations

Recommendations: Mid Staffs Inquiry

1,814 tracked recommendations 35 inquiries 290 match current filters Page 1 of 6

Recommendations issued by UK statutory and non-statutory inquiries, with their tracked government response and supporting evidence.

Recommendations

290 of 1,814 · page 1 of 6

Code	Recommendation	Inquiry	Response
F1	Implementing the recommendations It is recommended that: All commissioning, service provision regulatory and ancillary organisations in healthcare should consider the findings and recommendations of this …	Mid Staffs Inquiry (2013)	Accepted
F2	Putting the patient first The NHS and all who work for it must adopt and demonstrate a shared culture in which the patient is the priority …	Mid Staffs Inquiry (2013)	Accepted
F3	Clarity of values and principles The NHS Constitution should be the first reference point for all NHS patients and staff and should set out the system's common …	Mid Staffs Inquiry (2013)	Accepted
F4	Clarity of values and principles The core values expressed in the NHS Constitution should be given priority of place and the overriding value should be that patients …	Mid Staffs Inquiry (2013)	Accepted
F5	Clarity of values and principles In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that: Staff put patients before themselves; …	Mid Staffs Inquiry (2013)	Accepted
F6	Clarity of values and principles The handbook to the NHS Constitution should be revised to include a much more prominent reference to the NHS values and their …	Mid Staffs Inquiry (2013)	Accepted
F7	Clarity of values and principles All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both …	Mid Staffs Inquiry (2013)	Accepted in Part
F8	Clarity of values and principles Contractors providing outsourced services should also be required to abide by these requirements and to ensure that staff employed by them for …	Mid Staffs Inquiry (2013)	Accepted
F9	Fundamental standards of behaviour The NHS Constitution should include reference to all the relevant professional and managerial codes by which NHS staff are bound, including the …	Mid Staffs Inquiry (2013)	Accepted in Part
F10	Fundamental standards of behaviour The NHS Constitution should incorporate an expectation that staff will follow guidance and comply with standards relevant to their work, such as …	Mid Staffs Inquiry (2013)	Accepted in Part
F11	Fundamental standards of behaviour Healthcare professionals should be prepared to contribute to the development of, and comply with, standard procedures in the areas in which they …	Mid Staffs Inquiry (2013)	Accepted
F12	Fundamental standards of behaviour Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to …	Mid Staffs Inquiry (2013)	Accepted
F13	The nature of standards Standards should be divided into: Fundamental standards of minimum safety and quality – in respect of which non-compliance should not be tolerated. …	Mid Staffs Inquiry (2013)	Accepted
F14	The nature of standards In addition to the fundamental standards of service, the regulations should include generic requirements for a governance system designed to ensure compliance …	Mid Staffs Inquiry (2013)	Accepted in Part
F15	The nature of standards All the required elements of governance should be brought together into one comprehensive standard. This should require not only evidence of a …	Mid Staffs Inquiry (2013)	Accepted in Part
F16	Responsibility for setting standards The Government, through regulation, but after so far as possible achieving consensus between the public and professional representatives, should provide for the …	Mid Staffs Inquiry (2013)	Accepted
F17	Responsibility for setting standards The NHS Commissioning Board together with Clinical Commissioning Groups should devise enhanced quality standards designed to drive improvement in the health service. …	Mid Staffs Inquiry (2013)	Accepted in Part
F18	Responsibility for setting standards It is essential that professional bodies in which doctors and nurses have confidence are fully involved in the formulation of standards and …	Mid Staffs Inquiry (2013)	Accepted
F19	Gaps between the understood functions of separate regulators There should be a single regulator dealing both with corporate governance, financial competence, viability and compliance with patient safety and quality standards …	Mid Staffs Inquiry (2013)	Not Accepted
F20	Responsibility for regulating and monitoring compliance The Care Quality Commission should be responsible for policing the fundamental standards, through the development of its core outcomes, by specifying the …	Mid Staffs Inquiry (2013)	Accepted in Part
F21	Responsibility for regulating and monitoring compliance The regulator should have a duty to monitor the accuracy of information disseminated by providers and commissioners on compliance with standards and …	Mid Staffs Inquiry (2013)	Accepted in Part
F22	Responsibility for regulating and monitoring compliance The National Institute for Health and Clinical Excellence should be commissioned to formulate standard procedures and practice designed to provide the practical …	Mid Staffs Inquiry (2013)	Accepted in Part
F23	Responsibility for regulating and monitoring compliance The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of …	Mid Staffs Inquiry (2013)	Accepted
F24	Responsibility for regulating and monitoring compliance Compliance with regulatory fundamental standards must be capable so far as possible of being assessed by measures which are understood and accepted …	Mid Staffs Inquiry (2013)	Accepted
F25	Responsibility for regulating and monitoring compliance It should be considered the duty of all specialty professional bodies, ideally together with the National Institute for Health and Clinical Excellence, …	Mid Staffs Inquiry (2013)	Accepted
F26	Responsibility for regulating and monitoring compliance In policing compliance with standards, direct observation of practice, direct interaction with patients, carers and staff, and audit of records should take …	Mid Staffs Inquiry (2013)	Accepted
F27	Responsibility for regulating and monitoring compliance The healthcare systems regulator should promote effective enforcement by: use of a low threshold of suspicion; no tolerance of non-compliance with fundamental …	Mid Staffs Inquiry (2013)	Accepted
F28	Sanctions and interventions for non-compliance Zero tolerance: A service incapable of meeting fundamental standards should not be permitted to continue. Breach should result in regulatory consequences attributable …	Mid Staffs Inquiry (2013)	Accepted
F29	Sanctions and interventions for non-compliance It should be an offence for death or serious injury to be caused to a patient by a breach of these regulatory …	Mid Staffs Inquiry (2013)	Accepted
F30	Interim measures The healthcare regulator must be free to require or recommend immediate protective steps where there is reasonable cause to suspect a breach …	Mid Staffs Inquiry (2013)	Accepted
F31	Interim measures Where aware of concerns that patient safety is at risk, Monitor and all other regulators of healthcare providers must have in place …	Mid Staffs Inquiry (2013)	Accepted
F32	Interim measures Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take …	Mid Staffs Inquiry (2013)	Accepted
F33	Interim measures Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the …	Mid Staffs Inquiry (2013)	Accepted in Part
F34	Interim measures Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim …	Mid Staffs Inquiry (2013)	Accepted in Part
F35	Need to share information between regulators Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all …	Mid Staffs Inquiry (2013)	Accepted
F36	Use of information for effective regulation A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in …	Mid Staffs Inquiry (2013)	Accepted
F37	Use of information about compliance by regulator from: Quality accounts Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each …	Mid Staffs Inquiry (2013)	Accepted
F38	Use of information about compliance by regulator from: Complaints The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant …	Mid Staffs Inquiry (2013)	Accepted
F39	Use of information about compliance by regulator from: Complaints The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.	Mid Staffs Inquiry (2013)	Accepted in Part
F40	Use of information about compliance by regulator from: Complaints It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the …	Mid Staffs Inquiry (2013)	Accepted
F41	Use of information about compliance by regulator from: Patient safety alerts The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee …	Mid Staffs Inquiry (2013)	Accepted in Part
F42	Use of information about compliance by regulator from: Serious untoward incidents Strategic Health Authorities/their successors should	Mid Staffs Inquiry (2013)	Accepted
F43	Use of information about compliance by regulator from: Media Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility.	Mid Staffs Inquiry (2013)	Accepted
F44	Use of information about compliance by regulator from: Media Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was …	Mid Staffs Inquiry (2013)	Accepted in Part
F45	Use of information about compliance by regulator from: Inquests The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.	Mid Staffs Inquiry (2013)	Accepted in Part
F46	Use of information about compliance by regulator from: Quality and risk profiles The Quality and Risk Profile should not be regarded as a potential substitute for active regulatory oversight by inspectors. It is important …	Mid Staffs Inquiry (2013)	Accepted
F47	Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. …	Mid Staffs Inquiry (2013)	Accepted
F48	Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them …	Mid Staffs Inquiry (2013)	Accepted in Part
F49	Enhancement of monitoring and the importance of inspection Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring …	Mid Staffs Inquiry (2013)	Accepted
F50	Enhancement of monitoring and the importance of inspection The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.	Mid Staffs Inquiry (2013)	Accepted

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