Inquiries · Recommendations

Recommendations: Mid Staffs Inquiry

1,814 tracked recommendations 35 inquiries 290 match current filters Page 2 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 2 of 6

Code	Recommendation	Inquiry	Response
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
F59	Care Quality Commission independence strategy and culture Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the …	Mid Staffs Inquiry (2013)	Accepted in Part
F60	Consolidation of regulatory functions The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be …	Mid Staffs Inquiry (2013)	Accepted in Part
F61	Consolidation of regulatory functions A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such …	Mid Staffs Inquiry (2013)	Not 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
F64	Authorisation of foundation trusts The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this …	Mid Staffs Inquiry (2013)	Not 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
F72	Assessment process for authorisation The assessment for an authorisation of applicant for foundation trust status should include a full physical inspection of its primary clinical areas …	Mid Staffs Inquiry (2013)	Accepted
F73	Need for constructive working with other parts of the system The Department of Health's regular performance reviews of Monitor (and the Care Quality Commission) should include an examination of its relationship with …	Mid Staffs Inquiry (2013)	Accepted
F74	Enhancement of role of governors Monitor and the Care Quality Commission should publish guidance for governors suggesting principles they expect them to follow in recognising their obligation …	Mid Staffs Inquiry (2013)	Accepted
F75	Enhancement of role of governors The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the …	Mid Staffs Inquiry (2013)	Accepted in Part
F76	Enhancement of role of governors Arrangements must be made to ensure that governors are accountable not just to the immediate membership but to the public at large …	Mid Staffs Inquiry (2013)	Accepted
F77	Enhancement of role of governors Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to …	Mid Staffs Inquiry (2013)	Accepted
F78	Enhancement of role of governors The Care Quality Commission and Monitor should consider how best to enable governors to have access to a similar advisory facility in …	Mid Staffs Inquiry (2013)	Accepted
F79	Accountability of providers' directors There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for …	Mid Staffs Inquiry (2013)	Accepted in Part
F80	Accountability of providers' directors A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be …	Mid Staffs Inquiry (2013)	Accepted in Part
F81	Accountability of providers' directors Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude …	Mid Staffs Inquiry (2013)	Accepted
F82	Accountability of providers' directors Provision should be made for regulatory intervention to require the removal or suspension from office after due process of a person whom …	Mid Staffs Inquiry (2013)	Accepted
F83	Accountability of providers' directors If a "fit and proper person test" is introduced as recommended, Monitor should issue guidance on the principles on which it would …	Mid Staffs Inquiry (2013)	Accepted
F84	Accountability of providers' directors Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable …	Mid Staffs Inquiry (2013)	Accepted in Part
F85	Accountability of providers' directors Monitor and the Care Quality Commission should produce guidance to NHS and foundation trusts on procedures to be followed in the event …	Mid Staffs Inquiry (2013)	Accepted
F86	Requirement of training of directors A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of …	Mid Staffs Inquiry (2013)	Accepted
F87	Ensuring the utility of a health and safety function in a clinical setting The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should …	Mid Staffs Inquiry (2013)	Accepted in Part
F88	Information sharing The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators …	Mid Staffs Inquiry (2013)	Accepted in Part
F89	Information sharing Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and …	Mid Staffs Inquiry (2013)	Accepted in Part
F90	Assistance in deciding on prosecutions In order to determine whether a case is so serious, either in terms of the breach of safety requirements or the consequences …	Mid Staffs Inquiry (2013)	Accepted
F91	NHS Litigation Authority Improvement of risk management The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not …	Mid Staffs Inquiry (2013)	Accepted in Part
F92	NHS Litigation Authority Improvement of risk management The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3.	Mid Staffs Inquiry (2013)	Accepted
F93	NHS Litigation Authority Improvement of risk management The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, …	Mid Staffs Inquiry (2013)	Accepted in Part
F94	Evidence-based assessment As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to …	Mid Staffs Inquiry (2013)	Accepted
F95	Information sharing As the interests of patient safety should prevail over the narrow litigation interest under which confidentiality or even privilege might be claimed …	Mid Staffs Inquiry (2013)	Accepted
F96	Information sharing The NHS Litigation Authority should make more prominent in its publicity an explanation comprehensible to the general public of the limitations of …	Mid Staffs Inquiry (2013)	Accepted
F97	National Patient Safety Agency functions The National Patient Safety Agency's resources need to be well protected and defined. Consideration should be given to the transfer of this …	Mid Staffs Inquiry (2013)	Accepted in Part
F98	National Patient Safety Agency functions Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm …	Mid Staffs Inquiry (2013)	Accepted in Part
F99	National Patient Safety Agency functions The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative …	Mid Staffs Inquiry (2013)	Accepted in Part
F100	National Patient Safety Agency functions Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt …	Mid Staffs Inquiry (2013)	Accepted in Part

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