Inquiries · Recommendations

Recommendations: Mid Staffs Inquiry

1,814 tracked recommendations 35 inquiries 201 match current filters Page 1 of 5

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

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Recommendations

201 of 1,814 · page 1 of 5
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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