Inquiries · Recommendations
Recommendations: Mid Staffs Inquiry
1,814 tracked recommendations
35 inquiries
201 match current filters
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Recommendations issued by UK statutory and non-statutory inquiries, with their tracked government response and supporting evidence.
Recommendations
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| F51 |
Enhancement of monitoring and the importance of inspection
The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of …
|
Mid Staffs Inquiry (2013) | Accepted |
| F52 |
Enhancement of monitoring and the importance of inspection
The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage …
|
Mid Staffs Inquiry (2013) | Accepted |
| F53 |
Care Quality Commission independence strategy and culture
Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a …
|
Mid Staffs Inquiry (2013) | Accepted |
| F54 |
Care Quality Commission independence strategy and culture
Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to …
|
Mid Staffs Inquiry (2013) | Accepted |
| F55 |
Care Quality Commission independence strategy and culture
The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and …
|
Mid Staffs Inquiry (2013) | Accepted |
| F56 |
Care Quality Commission independence strategy and culture
The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, …
|
Mid Staffs Inquiry (2013) | Accepted |
| F57 |
Care Quality Commission independence strategy and culture
The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and …
|
Mid Staffs Inquiry (2013) | Accepted |
| F58 |
Care Quality Commission independence strategy and culture
Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there …
|
Mid Staffs Inquiry (2013) | Accepted |
| F62 |
Improved patient focus
For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into …
|
Mid Staffs Inquiry (2013) | Accepted |
| F63 |
Improved transparency
Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.
|
Mid Staffs Inquiry (2013) | Accepted |
| F65 |
Quality of care as a pre-condition for foundation trust applications
The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of …
|
Mid Staffs Inquiry (2013) | Accepted |
| F66 |
Improving contribution of stakeholder opinions
The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to …
|
Mid Staffs Inquiry (2013) | Accepted |
| F67 |
Focus on compliance with fundamental standards
The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for …
|
Mid Staffs Inquiry (2013) | Accepted |
| F68 |
Focus on compliance with fundamental standards
No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager …
|
Mid Staffs Inquiry (2013) | Accepted |
| F69 |
Focus on compliance with fundamental standards
The assessment criteria for authorisation should include a requirement that applicants demonstrate their ability to consistently meet fundamental patient safety and quality …
|
Mid Staffs Inquiry (2013) | Accepted |
| F70 |
Duty of utmost good faith
A duty of utmost good faith should be imposed on applicants for foundation trust status to disclose to the regulator any significant …
|
Mid Staffs Inquiry (2013) | Accepted |
| F71 |
Role of Secretary of State
The Secretary of State's support for an application should not be given unless he is satisfied that the proposed applicant provides a …
|
Mid Staffs Inquiry (2013) | Accepted |
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