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
CQC action
98match
Moorview Care (Derby)
The provider did not ensure people received person centred care which met their needs and preferences.
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
CQC action
93match
Chy Byghan Residential Home
The provider must ensure people are provided with person-centred care that meets their needs and reflects their 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 action
90match
Woodland Care Home
The registered provider had not provided person-centred, goal-orientated care that reflected the preferences of people who used the service.
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
CQC action
89match
Southwinds
The provider did not ensure that people received person centred care that met their needs and reflected their preferences.
Matched on
terms: care, centred, person
CQC action
89match
Reside at Southwood
Proper steps had not been taken to ensure that people receive appropriate person-centred care and treatment that is based on an assessment of their needs and preferences.
Matched on
terms: care, centred, person
CQC action
89match
Nower House
The failure to ensure person-centred care was a continued breach of regulation 9 (Need for consent) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Matched on
terms: care, centred, person
CQC action
89match
Benedict House Nursing Home
The provider must ensure people using the service receive person-centred care that reflects their needs or their personal preferences.
Matched on
terms: care, centred, person
CQC action
89match
Homesaints Limited
The provider must ensure people's preferences are fully explored, care is person-centred, concerns are responded to with a view to improving care, and people's care needs in relation to meals, care visit times and choice of staff are upheld.
Matched on
terms: care, centred, person
CQC action
86match
New Dawn Healthcare - Unit 18 Blackheath Business Centre
The registered person did not always ensure that care was delivered to people with a view to achieving their preferences and ensuring their needs were met.
Matched on
terms: care, person
CQC action
85match
Kettering General Hospital
The servicemust ensure the needs of patients with a learning disability or autistic people are regularly assessed and they are provided with person centred care.
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 (R99) below.)
Matched on
terms: care, person
CQC action
81match
Newland House
People were not receiving care which was person-centred or reflected personal preferences.
Matched on
terms: care, centred, 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
CQC action
77match
Benthorn Lodge
The registered person failed to ensure that the care and treatment provided to people was appropriate and met their needs and preferences. In addition the registered persons person had not made suitable arrangements to ensure that people were enabled to participate in activities that met their specific diverse needs and reflected their interests.
Matched on
terms: care, person
CQC action
77match
The Old Rectory
The provider did not ensure that people who used the service received individualised care that reflected their personal preferences. Regulation 9 (1).
Matched on
terms: care, person
CQC action
77match
Prospects for People with Learning Disabilities - 3 Norwich Road
People's care plans were not always written in a person centred way. In one care plan the person's name was incorrect on a number of occasions in their care plan. Some of the information in people's care records was duplicated across all three people's care plans we looked at.
Matched on
terms: care, centred, person
CQC action
77match
Copper Beeches Lodge
The provider must comply with Regulation 9 (Person-centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
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
CQC action
74match
Spindrift Care Home Limited
The provider was not working within the principles of the Mental Capacity Act 2005. The provider had not undertaken any assessment of people's capacity to make decisions. Decisions had been made on people's behalf without ensuring they were in the best interests of the person. People were restricted regardless of their capacity.
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
CQC action
73match
Havilah Office
The provider did not carry out collaboratively with the person an assessment of their needs and preferences for their care or design care with a view to achieving service user's preferences and ensuring their needs were met. Regulation 9(3)(a)(b)
Matched on
terms: care, person
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
PFD report
69match
Christopher Watson
Social care failed to ensure a vulnerable individual received, understood, or could read a letter offering help, and did not make direct contact to assess their capacity or needs.
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
Inquiry recommendation
69match
BRIS-1 - Ensure patient involvement in all treatment and care decisions
In a patient-centred healthcare service patients must be involved, wherever possible, in decisions about their treatment and care.
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
CQC action
66match
Assured Care Formby
Care plans did not detail people's likes. dislikes and preferences. People had not always been involved in planning their care.
Matched on
terms: care
CQC action
66match
Heritage Healthcare-Middlesbrough
The provider must ensure valid consent is obtained and recorded, and best interests decisions are made and documented where capacity is lacking.
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
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
Winterton House
Care did not always meet need or reflect people's preferences. Care or treatment was not always designed with a view to achieving service users' preferences and ensuring their needs were met.
Matched on
terms: care