Feedback not integrated
Failure of service providers to systematically collect and integrate feedback from staff, service users, and relatives to inform improvements.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
74match
R47 - Quarterly family feedback via external agency
The provider should actively seek family or carer feedback on the service user’s experience on a quarterly basis via an external agency and report the findings to the public part of a Board-level committee minutes (where these exist) and publish them on the provider’s website.
Matched on
terms: feedback
Committee recommendation
73match
#4 - Require all departments to collate feedback from whistleblowers at the end of the process.
The Cabinet Office and other departments do not seek feedback from whistleblowers and so are missing vital insights into the effectiveness of the process. The ‘whistleblowing heath check’ guidance from the Cabinet Office suggests departments should gather feedback from individuals on whether their concerns have been handled responsibly, professionally and in a positive manner. Feedback can provide a...
Matched on
terms: feedback
Inquiry recommendation
70match
R46 - Lived experience feedback via external agency
Where people with learning disabilities can participate, the provider should actively seek their lived experience feedback in relation to staff attitudes and behaviours on a quarterly basis through an external and independent agency (perhaps to be undertaken by the PCC), and report this to a public part of a Board-level committee and also publish it on the provider’s...
Matched on
terms: feedback
HSSIB recommendation
69match
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients...
Integrated care boards and organisations that provide mental health care can improve safety by involving people with lived experience and family carers in coaching for executive leaders. This could include creating learning networks within provider collaboratives. By embedding these roles, executive teams and non-executive directors would receive direct insights from those with personal experience of mental health services,...
Matched on
terms: integrated
Committee recommendation
65match
#13 - HMCTS user feedback mechanisms exist, but significant user concerns remain unaddressed.
It explained that it had several ways it can gather user feedback. For example, it told us that every director in HMCTS was sponsoring an area of the programme which allowed them to listen to user feedback first-hand. HMCTS also stated that it had “six or seven other new mechanisms” for getting better feedback, including webinars and an...
Matched on
terms: feedback
CQC action
65match
Royal Victoria Infirmary
The trust must ensure that feedback from staff is used to drive improvements to the quality and safety of services, and once improvements are identified they are made without delay.
Matched on
terms: feedback
CQC action
65match
Ellesmere Port Hospital
The trust must ensure staff feedback is captured and responded to appropriately to identify risks and drive improvement in services.
Matched on
terms: feedback
PHSO casework decision
65match
P-002847 - Birmingham and Solihull Integrated Care Board
Miss N complained the ICB failed to implement promised service improvements regarding her father's continuing healthcare and delayed arranging a meeting to discuss her concerns.
Matched on
terms: integrated
CQC action
64match
The Peter Gidney Neurodisability Centre
We recommend that the provider reviews how it responds to feedback from people and their relatives to make service improvements.
Matched on
terms: feedback
Committee recommendation
62match
#9 - Publish guidance on providing timely, detailed, and consistent feedback for all funding bids.
We recommend that the DLUHC provides better guidance on how it will provide feedback on bids. The guidance must set out that feedback is timely, detailed, and consistent. This is especially important for levelling up funds as the quality of DLUHC’s feedback can hinder future applications which can be to the detriment of local communities. Feedback must also...
Matched on
terms: feedback
Inquiry recommendation
61match
BRIS-28 - Routinely seek, act on, and publish patient feedback and experience surveys across NHS
Patients must be given the opportunity to pass on views on the service which they have received: all parts of the NHS should routinely seek and act on feedback from patients as to their views of the service. In addition, formal, systematic structured surveys of patients’ experience of their care (not merely satisfaction surveys) should be routinely conducted...
Matched on
terms: feedback
Committee recommendation
61match
#7 - First Report - Parliamentary and Health Service Ombudsman Scrutiny 2020–21
The Committee recommends that the PHSO learns from and implements best practice at the Local Government and Social Care Ombudsman by publishing feedback scores about its service, split between those complainants who were happy with the result of their case and those who were not. This will allow for a better understanding of the service levels provided by...
Matched on
terms: feedback
CQC action
61match
William Harvey Hospital
The trust should ensure it seeks and acts quickly on feedback from staff for the purposes of continually evaluating and improving services.
Matched on
terms: feedback
HMICFRS recommendation
61match
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS doesn’t engage with or seek feedback from staff to understand their needs. We found this to especially be the case with some under-represented groups. When staff raise issues and concerns, the service doesn’t respond quickly enough. Recommendation: The service should improve communications between staff and senior managers, so concerns are responded to...
Matched on
terms: feedback
CQC action
60match
Charmes Care
The registered persons failed to have effective systems in place to assess, monitor and improve the quality and safety of the service and to to seek and act on feedback from people, relatives, and staff to continually evaluate and improve the service.
Matched on
terms: feedback
PFD report
57match
Anne Bradley
Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system prevented endoscopists from learning about tattooing issues or incorrect tumour identification.
Matched on
terms: feedback
Committee recommendation
57match
#8 - DLUHC lacks a consistent, department-wide process for providing competitive bid feedback.
We heard evidence which brought into question the extent of support provided to applicants or unsuccessful applicants by DLUHC. There is a wide gap in perception between the quality of feedback the DLUHC said it had provided and the quality of feedback applicants said they had received. DLUHC does not appear to have a department-wide process which allows...
Matched on
terms: feedback
Committee recommendation
57match
#6 - First Report - Parliamentary and Health Service Ombudsman Scrutiny 2020–21
The PHSO have improved the data output about their own performance in recent years, which the Committee applauds. Nevertheless, the Committee is of the view that even more open and transparent access to feedback data will enable external stakeholders to give an accurate judgement on the work of the PHSO. One of the ways of doing that is...
Matched on
terms: feedback
CQC action
57match
The County Hospital
The service should consider improving the response when requesting patient feedback.
Matched on
terms: feedback
CQC action
57match
Royal Sussex County Hospital
The trust must ensure communication structures for staff are clear, easy to follow, and that there are feedback mechanisms implemented for staff who raise individual concerns.
Matched on
terms: feedback
Committee recommendation
56match
#19 - Thirteenth Report - Initial lessons from the government’s response to the COVID-19 pandemic
Our previous work has shown a mixed picture in terms of the views of end users regarding the satisfaction and success of programmes introduced in response to the pandemic. Gathering feedback from end users and frontline workers is vital for monitoring the effectiveness of interventions and improving existing processes.41 We asked what structures had been put in place...
Matched on
terms: feedback
HSSIB recommendation
56match
Outpatient appointments intended but not booked after inpatient stays
HSIB recommends that NHS England and NHS Improvement develops standards and an operating framework that describes the assurance required for all outpatient appointment booking processes, including after an inpatient stay. The assurance should include feedback mechanisms which provide safeguards that intended outpatient appointments are booked. Ideally, solutions will use technology and automation to create resilience and efficiency so...
Matched on
terms: feedback
CQC action
56match
Montagu Hospital, Mexborough
Thetrustmustensurestafffeelsupportedtospeakupbyseekingandactingonfeedbackfromrelevantpersonsorotherpersonsontheserviceprovidedinthecarryingonoftheregulatedactivity,forthepurposeofcontinuallyevaluatingandimprovingsuchservices.TheTrustBoardmusthaveeffectiveoversightofallFreedomtoSpeakUpactions.
Matched on
terms: feedback
CQC action
56match
Ashbourne House - Torquay
The provider did not have effective systems and processes in place to ensure the ongoing monitoring and quality of the service. People's feedback was not obtained to improve and develop the service. The provider did not act on feedback from health and social care professionals in order to improve the service for people.
Matched on
terms: feedback
Inquiry recommendation
56match
BRIS-166 - PCTs must involve public in commissioning hospital services and gather feedback
Primary care trusts (and groups), given their capacity to influence the quality of care in hospitals, must involve patients and the public, for example through each PCG/T’s Patient and Advocacy Liaison Service. They must make efforts systematically to gather views and feedback from patients. They must pay particular attention to involving their local community in decision-making about the...
Matched on
terms: feedback
PHSO casework decision
56match
P-002807 - North Cumbria Integrated Care NHS Foundation Trust
Miss L complained staff failed to escalate concerns about her baby's heart rate, denied a scan, missed placenta abruption signs, and delayed delivery, leading to her son's death.
Matched on
terms: integrated
PHSO casework decision
56match
P-003162 - Tameside and Glossop Integrated Care NHS Foundation Trust
Mrs N complained the Trust's account of service improvements was insufficient following missed antibiotic doses, lack of consultant input, and poor critical care decisions for her mother.
Matched on
terms: integrated
PFD report
53match
Venkata Kagga
Critical safety features for button batteries in household devices are lacking, and national safety alerts are not effectively sustained. Hospital policies for paediatric assessment and compliance were not followed, exacerbated by poor information sharing across services.
Matched on
classifier match
PFD report
53match
Ffion Jones
The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between external healthcare professionals and ambulance staff to ensure proper assessment of response urgency.
Matched on
classifier match
PFD report
53match
Arlo Lambert
The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to capture early reflective staff accounts, impeding effective safety improvements.
Matched on
classifier match
Committee recommendation
53match
#30 - Eighth Report: Economic impact of coronavirus: the challenges of recovery
One of the clear strengths of the Treasury’s response in the initial stages of the crisis has been its willingness to listen and adjust its policies in response to feedback. However, we are disappointed in its refusal to implement recommendations from our first Report and hope that this does not indicate growing intransigence going forward. The continued uncertainty...
Matched on
terms: feedback
CQC action
53match
Withington Community Hospital
Provide patient feedback at a local level.
Matched on
terms: feedback
Committee recommendation
52match
#16 - Thirty-First Report - Environmental Land Management Scheme
The Tenant Farmers Association told us that its members participating in the pilot were finding the scheme guidance confusing, with an onus on farmers to decide what they think is best to enable the delivery of public goods.48 The National Farmers’ Union told us that it had received similar feedback from farmers that the scheme felt complicated and...
Matched on
terms: feedback
CQC action
52match
Liverpool Walk in Centre
Review the significant event reporting system to ensure staff receive feedback when an incident has been reported.
Matched on
terms: feedback
Inquiry recommendation
52match
F198 - Measuring cultural health
Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing workplaces and teams, which build on the experience and feedback of nursing staff using a robust methodology, such as the "cultural barometer".
Matched on
terms: feedback
Inquiry recommendation
52match
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 be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report they make, including information about any action taken or reasons for not acting.
Matched on
terms: feedback
NAO recommendation
52match
Digital Services at the Border
The Department should: a) build on the recent progress the programme board has made in understanding risks, and its tracking of progress, to set up ways of working in line with the scale and pace of implementation it now requires to deliver the programme. This should include ensuring that feedback mechanisms with front-line users allow it to respond...
Matched on
terms: feedback
Inquiry recommendation
51match
F158 - Training and training establishments as a source of safety information
The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from students and tutors on compliance by placement providers with minimum standards of patient safety and quality of care, and should generally place the highest priority on the safety of patients.
Matched on
terms: feedback
PFD report
49match
Gary Richards
Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations from a previous incident report.
Matched on
classifier match
PFD report
49match
Raymond Davidson
Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact not directly with the patient compromised the initial clinical review.
Matched on
classifier match
PFD report
49match
Edward Lundy
Poor continuity of care, inadequate family consultation on discharge risks, and lack of evidence for implementing recommended improvements in mental health risk management for GP trainees were identified.
Matched on
classifier match
PFD report
49match
Andrew Wing
A CT Aorta was not performed despite an abnormal X-ray and suspected aortic dissection, partly because radiologists reviewing images remotely receive insufficient clinical information for accurate diagnosis.
Matched on
classifier match
PFD report
49match
Ruben Bousquet
Weak reporting and information sharing processes for food allergy fatalities hinder timely investigations and learning. The feasibility of food businesses carrying adrenaline auto-injectors also needs official investigation.
Matched on
classifier match
PFD report
49match
Michael Jaggs
An agency nurse provided suboptimal care, but the agency failed to provide additional training or encourage reflective learning, unlike the hospital, raising concerns about safety improvements.
Matched on
classifier match
PFD report
49match
Thomas Ithell
The Health Board failed to raise incident reports or investigate a patient being lost to follow-up, citing time constraints and an un-user-friendly system, undermining patient safety governance.
Matched on
classifier match
PFD report
49match
Eden Street
Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical updates on deteriorating neurodiverse patients being missed by clinicians.
Matched on
classifier match
PFD report
49match
Etta-Lili Stockwell-Parry
The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly shared and lacked context, hindering genuine organizational change.
Matched on
classifier match
PFD report
49match
David Heffer
The treating doctor was not informed of the patient's readmission for a complication, and medical records were incomplete and illegible, hindering proper care and investigation.
Matched on
classifier match
Committee recommendation
49match
#18 - Forty-First Report - COVID 19: the free school meals voucher scheme
In terms of things it could have done better, the Department said that, if it were to do the same thing again, it would try to find a way to do more user testing before the scheme started. The Department said that a lack of user-testing before the scheme was launched accounted for much of what led to...
Matched on
classifier match
CQC action
49match
The Princess Royal Hospital
The service should ensure all patients are able to discuss any concerns with staff.
Matched on
classifier match