No person-centred care
Failure to ensure the provision of truly person-centred care that meets individual needs, preferences, and promotes dignity.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
100match
#3 - Current mental health services fail to provide person-centred, holistic care
Service users, their families, carers and loved ones have been clear: high- quality care must be person-centred, responsive to the full range of needs individuals experience, and ensure involvement of their wider networks. Current services too often fall short—focusing narrowly on diagnosis, overlooking physical health, and failing to support people with housing, employment, and social connection. People are...
Matched on
terms: care, centred, person
Inquiry recommendation
99match
R100 - Person-centred day activities and supported employment
Trusts, private and 3rd sector care providers must ensure that person-centred day activities (including supported employment where appropriate) should be available and offered to all people with learning disabilities and autistic people. This should be monitored through Trust delivery plans.
Matched on
terms: care, centred, person
Inquiry recommendation
99match
R12 - Person-centred care plans with family involvement
Care plans must be live, person-centred documents. This requires joint ownership with people with learning disabilities and their families rather than simply professional records. While professionals necessarily lead assessments, families should be actively involved in identifying needs. Resulting care plans should be shared with the service user themselves (where appropriate) and families, who should be able to challenge...
Matched on
terms: care, centred, person
GIRFT recommendation
94match
Mental Health – Adult Crisis and Acute Care
Trusts need to ensure that person-centred care and co-production of care plans is standard (including to the maximum extent feasible within the law for those detained under the MHA). For people who lack capacity, care planning should follow the principles and rules set out in the Mental Capacity Act. a Trusts to ensure the electronic health record clearly...
Matched on
terms: care, centred, person
HSSIB recommendation
93match
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients...
Organisations that provide mental health care can improve patient safety by adopting a comprehensive person-centred care approach that prioritises the individual needs, preferences and rights of each patient. This approach should ensure consistent access to meaningful therapeutic activities, actively involve families in care planning and decision making, and create supportive environments tailored to the sensory and emotional needs...
Matched on
terms: care, centred, person
CQC action
93match
Royal Victoria Infirmary
The service must ensure that people who use the service receive person centred care and treatment that is appropriate, meets their needs and reflect their personal preferences.
Matched on
terms: care, centred, person
PHSO recommendation
90match
Discharge from mental health care: making it safe and patient-centred
NHS England and Integrated Care Boards should make sure that people who are being discharged from mental health settings can choose a nominated person to be involved in discussions and decision-making around transitions of care.
Matched on
terms: care, centred, person
HSSIB recommendation
90match
Care delivery within community mental health teams
NHS England has written to all mental health trusts in England to highlight the importance of taking a person-centred approach to psychosocial assessments and safety planning. The communication asks trusts to move away from risk assessment tools that stratify an individual’s risk of suicide or self-harm.
Matched on
terms: care, centred, person
CQC enforcement action
90match
Warning Notice: Kent and Medway NHS and Social Care Partnership Trust
The Care Quality Commission issued a warning notice to Kent and Medway NHS and Social Care Partnership Trust, telling it to make urgent improvements. This followed an inspection in March which found a decline in the quality of care provided, with concerns that care was not always safe or personalised to people's needs. Inspectors found people were sometimes...
Matched on
terms: care, centred, person
HSSIB recommendation
89match
Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of...
Organisations can improve patient safety by listening to and communicating with patients, their families and carers, about the safety and wellbeing of people who have self-harmed and/or are expressing suicidal thoughts. It is important that this involvement starts from the point of a patient’s admission through to their discharge from inpatient mental health wards and during follow up....
Matched on
terms: care, centred, person
Inquiry recommendation
82match
R5 - Named person for care plans
Any service user with a learning disability should have a named person (a key individual) responsible for their care plans and this person should be involved in and record the discussion with the family and the discussion with any relevant MDT and sign off the final decision. (And see Recommendation 99).
Matched on
terms: care, person
CQC action
81match
Sunderland Royal Hospital
The trust should ensure patients living dementia have personalised plans of care which consider their individual needs and preferences.
Matched on
terms: care, person
CQC action
81match
South Tyneside District Hospital
The trust should ensure patients living dementia have personalised plans of care which consider their individual needs and preferences.
Matched on
terms: care, person
HSSIB recommendation
78match
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services...
Providers of inpatient children and young people’s mental health services can improve patient safety by ensuring there is not a blanket approach to safeguarding mitigation measures based on a person’s age, and that mitigation measures are individualised and based on behaviours and risks.
Matched on
terms: care, person
HSSIB recommendation
77match
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation create the conditions for staff to empower and enable patients, their families and carers – through a person-centred approach – to self-manage insulin where appropriate?
Matched on
terms: care, centred, person
CQC action
77match
William Harvey Hospital
The trust should consider introducing education facilities for children staying on wards. Regulation 9(1): Person-centred care.
Matched on
terms: care, centred, person
HSSIB recommendation
76match
Electronic prescribing and medicines administration systems and safe discharge
It is recommended that NHS England and NHS Improvement include in the Medication Safety Programme shared decision making and improved patient access to medication information across all sectors of care, to ensure a person-centred approach to safe and effective medicines use.
Matched on
terms: care, centred, person
LGO / SPSO decision
76match
21-016-787 - Kent County Council
Summary: Mr X complains the Council’s care provider, Expertise Homecare (Ashford), failed to meet his late mother’s needs, putting her at risk of harm. His mother did not always receive person centred care and was put at risk of harm by some of her care workers. This caused avoidable distress to her and Mr X. The Council needs...
Matched on
terms: care, centred, person
GIRFT recommendation
74match
Adult Critical Care
Develop pathways for post-critical care follow-up, and consider which approach best meets patient needs. a GIRFT to support trusts and Operational Deliver Networks (ODNs) to develop pathways and to ensure that they adhere to upcoming guidance from FICM.
Matched on
terms: care
PFD report
73match
Barry Horrocks
The prison environment was not adapted to Mr Horrocks' daily living needs, and no care providers within the prison system accepted responsibility for assisting with his intimate personal care requirements.
Matched on
terms: care, person
Committee recommendation
73match
#4 - Stigma and discrimination undermine equitable and culturally appropriate mental health services
Experiences of stigma, discrimination, and lack of culturally appropriate or personalised support were frequently reported, particularly by racialised communities, neurodivergent individuals, and those with disabilities. 74 Where care was described as high-quality, it was inclusive, responsive, and tailored to individual needs. Equity must be integral to the delivery of high- quality community mental health services. (Conclusion, Paragraph 55)
Matched on
terms: care, person
GIRFT recommendation
73match
Breast Surgery
Ensure that new breast patient referral and assessment pathways are timely and centred around the individual with the aim of providing the best outcomes and experience. a) Provide primary care support and guidance to allow best use of the access pathway. b) Ensure that access and assessment pathways are evidence-based, risk-adapted and standardised to support safety and cost...
Matched on
terms: care, centred
Committee recommendation
70match
#16 - Publish clear guidance on key worker roles to ensure care coordination for service users.
In some areas, the emphasis on care coordination may have been lost through the rollout of the CMHF. We recommend that NHS England publish clear guidance on the role of key workers to ensure all service users have access to a named individual responsible for coordinating their care. (Recommendation, Paragraph 110)
Matched on
terms: care
Committee recommendation
70match
#6 - Co-design new mental health care models with experts by experience
Our conclusions in this Chapter try to reflect what service users told us they wanted. This must be reflected in service design. As new models of care are commissioned and implemented, these must be co-designed with experts by experience to ensure services deliver the high quality care such users need and deserve. (Recommendation, Paragraph 60) Recent reforms to...
Matched on
terms: care
HSSIB recommendation
70match
Mental health: attempted suicide while under the care of community services
Early exploration of adjustments that individual service users might need to engage in the triage and referral processes.
Matched on
terms: care
Committee recommendation
69match
#17 - Ensure active parental involvement in all SEND processes with independent advocacy and resources
Parents and carers must be actively and meaningfully involved in all processes that affect their child’s education, support, and overall wellbeing. This includes being fully informed and invited to participate in all relevant meetings where decisions about their child’s needs or provision are being discussed at the school and local authority level. Families should have access to independent...
Matched on
terms: care
GIRFT recommendation
69match
Ophthalmology
Undertake a detailed assessment of patient pathways to identify needs for more space to offer patient-centred care in different settings. Actions: a) Providers and commissioners to assess pathways and identify any areas where space may be a constraint on their overall capacity or their ability to deliver patient-centred care. b) GIRFT to work with NHS Improvement to examine...
Matched on
terms: care, centred
GIRFT recommendation
69match
Cardiology
Care pathway redesign using digital tools needs to be clinically led and patient centred. Examples of good practice can be found in the NHSX Cardiology Digital Playbook and appropriate governance standards should be adhered to. a) GIRFT will support ongoing work of NHS Digital and NHSX in (including NHS Digital Playbook) the digital transformation of cardiology services.
Matched on
terms: care, centred
Scottish FAI
68match
James Hutchison
(5) Recommendations I make the following recommendations (where I refer to a nursing home it should be understood that I am referring to a nursing home for elderly and mentally infirm persons, an EMI home) :- (a) When any elderly and mentally infirm person (probably therefore a person suffering from dementia) is to be admitted to a nursing...
Matched on
terms: care, person
Committee recommendation
66match
#1 - FGM survivors often lack awareness of long-term health complications and care needs
Survivors of female genital mutilation (FGM) experience profound physical, emotional and psychosexual consequences and require specialised care and support to manage these impacts. Despite this, survivors may not be aware that the health complications they experience are a consequence of FGM, meaning awareness among survivors of the long-term health implications of FGM is vital. (Conclusion, Paragraph 18)
Matched on
terms: care
Committee recommendation
66match
#2 - Lack of continuity of care fragments support for people with severe mental illness
Continuity of care is a necessity for people with severe mental illness. It is essential to the delivery of high-quality care. When it is present, it prevents crisis, builds trust, and supports recovery. When it is absent, it fragments support, burdens families, and puts lives at risk. This continuity must be built into the design of mental health...
Matched on
terms: care
HSSIB recommendation
66match
Patient care in temporary care environments
Does your organisation ensure that patients in temporary care environments are regularly engaged with to ensure that they have food, water, are comfortable, understand what is happening to them and what the plan is going forward?
Matched on
terms: care
HSSIB recommendation
66match
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to adults — HSSIB
Those involved in the design of new and upgraded built environments for mental health inpatient settings can improve patient safety and the delivery of therapeutic care by involving relevant stakeholders in design processes. Stakeholders include people with lived experience (patients and staff) and experts in human factors and ergonomics. Any design should also consider the changing needs of...
Matched on
terms: care
GIRFT recommendation
66match
Paediatric Critical Care
Ensure that specialist paediatric pathways are more closely aligned, so that a child with multiple comorbidities receives co-ordinated care in one tertiary hub whenever possible. a Establish a Children's Strategic Forum (CSF) in each region, with NHS England and NHS Improvement commissioning team oversight. The CSF should include clinical representation from each paediatric ODN and other non-ODN specialist...
Matched on
terms: care
PFD report
65match
Leonard Hudson
The coroner identified a failure to follow the Trust's pressure ulcer policy, including inadequate incident reporting and risk identification. Further concerns related to insufficient record-keeping, confusion in patient care arrangements, and a lack of contingency for physiotherapy provision.
Matched on
terms: care
Committee recommendation
65match
#44 - Ensure women's health hubs meet specific demographic needs, accounting for religious and cultural considerations.
Integrated care boards must ensure that their hubs meet the specific demographic needs of their populations, particularly accounting for religious and cultural considerations.
Matched on
terms: care
HSSIB recommendation
65match
Investigation report: Mental health inpatient settings - out of area placements
HSSIB recommends that the Department of Health and Social Care includes the documenting of patient, family and carers’ wishes and preferences within the Mental Health Bill. This will ensure all patient, family and carer voices are considered in decisions relating to where the patient identifies they would like to be close to, for example the patient’s home or...
Matched on
terms: care
CQC action
65match
The Princess Royal Hospital
The service must provide care that meets the needs, and reflect the preferences, of patients.
Matched on
terms: care
CQC action
65match
Scarborough Hospital
The trust must ensure they are delivering fundamental standards of care and patients receives safe and effective care that meet their needs.
Matched on
terms: care
CQC action
65match
Salford Royal Hospital
The service should ensure patients receive timely pain relief to ensure that care and treatment meets their needs.
Matched on
terms: care
CQC action
65match
Royal Shrewsbury Hospital
The service must provide care that meets the needs, and reflect the preferences, of patients.
Matched on
terms: care
CQC action
65match
Rochdale Infirmary
The service should ensure patients receive timely pain relief to ensure that care and treatment meets their needs.
Matched on
terms: care
CQC enforcement action
65match
Warning Notice: Tameside Hospital NHS Foundation Trust
The Care Quality Commission reviewed information and visited the trust on 9 March 2011, finding that care was falling short of essential standards in three areas, including safe and appropriate care and meeting individual dietary needs. CQC is requiring Tameside Hospital NHS Foundation Trust to take action to comply with these essential standards.
Matched on
terms: care
GIRFT recommendation
64match
Stroke
ISDNs should work with stroke teams to review current provision of Life after Stroke pathways. This should include access to psychological care, voluntary sector support and appropriate patient directed follow-up. a) Review current models of service delivery across providers and consider ISDN footprint commissioning with single lead commissioner and service specification. b) Finalise the Life After Stroke service...
Matched on
terms: care, person
PPO recommendation
64match
The Head of Healthcare
The Head of Healthcare should review the process for managing and monitoring long-term conditions to ensure the development of meaningful patient-centred care plans.
Matched on
terms: care, centred
Inquiry recommendation
62match
3 - Bereavement care
The National Bereavement Care Pathway for neonatal death should be implemented nationally and in all Trusts by 31 August 2027.
Matched on
terms: care
Inquiry recommendation
62match
R86 - PCC information on quality of care standards
The PCC should support service users/families and provide information on what constitutes good quality care for people with learning disabilities and autistic people, and how to spot when care is falling short.
Matched on
terms: care
Committee recommendation
62match
#16 - NHS fails patients during routine reproductive procedures, neglecting duty of care and pain management.
The NHS is failing many patients who undergo routine reproductive healthcare procedures such as hysteroscopy, IUD fitting and cervical screening. In too many cases, we find that a duty of care from gynaecologists and other medical practitioners is absent. Women are being pressured into enduring severe pain and find that they are ignored or belittled by those charged...
Matched on
terms: care
NCEPOD recommendation
62match
Mental Healthcare in Young People and Young Adults
Matched on
terms: care
NCEPOD recommendation
62match
Physical Healthcare in Mental Health Inpatient Settings
Matched on
terms: care