Quality and safety oversight
Failure to adequately assess, monitor, evaluate, and improve the quality and safety of services, hindering continuous improvement.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
HSSIB recommendation
94match
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
HSSIB recommends that the Care Quality Commission reviews the sector-level assessment frameworks it is developing to include assurance of ongoing compliance with the digital clinical safety standard (DCB0160) for electronic prescribing and medicines administration (ePMA) software. This will help to ensure oversight of ePMA functionality to improve patient safety.
Matched on
terms: oversight, quality, safety
HSSIB recommendation
85match
Insulin: supporting safe administration in inpatient settings
HSSIB recommends that NHS England/Department of Health and Social Care sets out the expectations and responsibilities of NHS trusts, integrated care boards and NHS England for the oversight and assurance of inpatient diabetes care. This should support organisations to implement and act on improvements shared in national guidance, recommendations and audit data. It should also include how existing...
Matched on
terms: oversight, quality, safety
Scottish FAI
83match
James Osbourne Murray
[141] There are two recommendations which I wish to make. [142] Firstly, I have seen nothing to suggest that Interflex have reviewed their health and safety procedures in the same way that Drummond Distribution have. If that has not been carried out by Interflex, I recommend they do so immediately. They should review existing (or prepare new) risk...
Matched on
terms: quality, safety
CQC enforcement action
83match
Warning Notice: Kettering General Hospital NHS Foundation Trust
The Care Quality Commission (CQC) told Kettering General Hospital NHS Foundation Trust it must make urgent improvements to comply with national standards of quality and safety. This followed an unannounced inspection in March 2013 which found that standards relating to cleanliness and infection control, supporting workers, and assessing and monitoring the quality of service provision were not being...
Matched on
terms: quality, safety
CQC action
81match
Wythenshawe Hospital
The service must assess, monitor and improve the quality and safety of the services provided in a timely way. Regulation 17(2)(a)
Matched on
terms: quality, safety
CQC action
81match
Worcestershire Royal Hospital
The trust should have systems or processes to assess, monitor and identify improvements of the quality and safety of sepsis management.
Matched on
terms: quality, safety
CQC action
81match
University Hospital of Hartlepool
The service must ensure there are systems and processes in place to assess, monitor and improve the quality and safety of the services in respect of restrictive practices.
Matched on
terms: quality, safety
PHSO recommendation
81match
Broken trust: making patient safety more than just a promise
As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses them. This should include where local investigations did not take place, or did not find that things went wrong, but PHSO or another independent...
Matched on
terms: oversight, quality, safety
HSSIB recommendation
78match
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Use the patient safety incident response standards and oversight roles and responsibilities specification to assess organisational support and where further resource is needed for PSIRF implementation.
Matched on
terms: oversight, safety
HSSIB recommendation
77match
Medication not given: administration of time critical medication in the emergency department
NHS trusts can improve patient safety by using the information contained in the information pack for the Royal College of Emergency Medicine’s Quality Improvement Programme on time critical medications to assess their preparedness and make local improvements in identifying, prescribing, and administering time critical medications in emergency departments.
Matched on
terms: quality, safety
CQC action
77match
Worthing Hospital
The trust must review its audit monitoring systems to effectively improve the quality and safety of the services.
Matched on
terms: quality, safety
CQC action
77match
Westmorland General Hospital
The trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service.
Matched on
terms: quality, safety
CQC enforcement action
77match
Warning Notice: Gloucestershire Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued Gloucestershire Hospitals NHS Foundation Trust with a warning notice following an inspection of its surgical services. The inspection was undertaken in response to concerns received about the safety and quality of the services, including staff whistleblowing and the number of never events reported. CQC required the trust to make significant improvements in...
Matched on
terms: quality, safety
CQC enforcement action
77match
Warning Notice: Countess of Chester Hospital NHS Foundation Trust
The Care Quality Commission rated Countess of Chester Hospital NHS Foundation Trust as 'requires improvement' and took enforcement action following an inspection in February and March. CQC served the trust with two warning notices, requiring urgent improvements in the effectiveness of its leadership and the safety of its maternity service. Inspectors found that standards of patient care remained...
Matched on
terms: quality, safety
CQC enforcement action
77match
Warning Notice: University Hospitals Sussex NHS Foundation Trust
The Care Quality Commission (CQC) carried out an unannounced focused inspection of University Hospitals Sussex NHS Foundation Trust's maternity and surgical services during September and October 2021, in response to concerns about safety and quality. Following the inspection, CQC issued a warning notice to the trust. This notice requires the trust to take action to ensure significant improvements...
Matched on
terms: quality, safety
CQC enforcement action
77match
Warning Notice: South London and Maudsley NHS Foundation Trust
The Care Quality Commission (CQC) has told South London and Maudsley NHS Foundation Trust that it must make urgent improvements to the quality of one of its acute wards for adults of working age and psychiatric intensive care units (PICU). Inspectors visited the Jim Birley Unit in December to follow up on concerns about the safety and quality...
Matched on
terms: quality, safety
CQC enforcement action
76match
Warning Notice: Central and North West London NHS Foundation Trust
The Care Quality Commission formally warned Central and North West London NHS Foundation Trust that it must improve the care it provides at the Campbell Centre, Milton Keynes, and 3 Beatrice Place, Kensington. At the Campbell Centre, warning notices were issued for not meeting standards in care and welfare, safety and suitability of premises, and assessing and monitoring...
Matched on
terms: quality, safety
CQC enforcement action
76match
Warning Notice: Salisbury NHS Foundation Trust
The Care Quality Commission (CQC) told Salisbury NHS Foundation Trust that improvements needed to be made in its maternity and spinal services at Salisbury District Hospital following an inspection on 31 March 2021. CQC found that governance arrangements were not clear and safety concerns were not consistently identified or addressed quickly enough in maternity services. In the spinal...
Matched on
terms: quality, safety
HSSIB recommendation
74match
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you identify and facilitate proactive communication with a point of contact at the integrated care board with oversight of the care pathway?
Matched on
terms: oversight, safety
Committee recommendation
73match
#8 - 4th Report - Homecare medicines services: an opportunity lost
No one—not the Government, not NHS England, not patient groups, not regulators, knows how often, nor how seriously patients suffer harm from service failures in homecare. This indicates a significant failure of oversight and hinders the ability of NHS England to ensure patient safety.
Matched on
terms: oversight, safety
CQC action
73match
Wavertree Bungalow
The provider and registered manager must effectively monitor all key aspects of the safety and quality of the service being provided.
Matched on
terms: quality, safety
CQC enforcement action
73match
Warning Notice: University Hospitals Birmingham NHS Foundation Trust
The Care Quality Commission (CQC) served University Hospitals Birmingham NHS Foundation Trust with a warning notice following inspections carried out in December. CQC found that the trust needed to make significant and immediate improvements to its staffing levels in medical care at Good Hope Hospital. The notice was served to ensure the trust makes clear changes to improve...
Matched on
terms: quality, safety
CQC enforcement action
73match
Warning Notice: Surrey and Borders NHS Foundation Trust
The Care Quality Commission told Surrey and Borders NHS Foundation Trust it must make improvements to its acute wards for adults of working age and psychiatric intensive care units to keep patients safe. CQC highlighted serious concerns surrounding patient safety on The Abraham Cowley Unit following an inspection in June 2020, requiring the trust to submit information explaining...
Matched on
terms: quality, safety
CQC enforcement action
73match
Warning Notice: Peterborough and Stamford Hospitals NHS Foundation Trust
The Care Quality Commission told Peterborough and Stamford Hospitals NHS Foundation Trust that it must take action to improve services at Peterborough City Hospital. Following a review of compliance, inspectors found the trust was not meeting five essential standards of quality and safety, including care and welfare, safety and suitability of premises, and records.
Matched on
terms: quality, safety
CQC enforcement action
73match
Warning Notice: Kent and Medway NHS and Social Care Partnership Trust
The Care Quality Commission demanded that Kent and Medway NHS and Social Care Partnership Trust take action to improve services following a review in November 2010. The review found that two hospitals, William Harvey Hospital in Ashford and a KMPT unit at Medway Maritime Hospital, were not meeting essential standards for the care and welfare of people and...
Matched on
terms: quality, safety
CQC enforcement action
72match
Warning Notice: Lincolnshire Partnership NHS Foundation Trust
The Care Quality Commission told Lincolnshire Partnership NHS Foundation Trust that it must take action to improve the care of those accessing its specialist mental health and learning disability services. Reports identified areas for improvement including the safety and suitability of hospital premises, care and welfare of people, cleanliness and infection control, staffing, respecting and involving people, and...
Matched on
terms: quality, safety
CQC enforcement action
72match
Warning Notice: Mid Essex Hospital Services NHS Trust
The Care Quality Commission (CQC) has told Mid Essex Hospital Services NHS Trust it must make urgent improvements to comply with national standards of quality and safety. This followed an unannounced inspection at Broomfield Hospital in Chelmsford, Essex, which found the trust was not meeting national standards relating to the care and welfare of people who use services...
Matched on
terms: quality, safety
CQC enforcement action
72match
Warning Notice: University Hospitals Plymouth NHS Trust
The Care Quality Commission (CQC) issued University Hospitals Plymouth NHS Trust with a warning notice following an inspection of Derriford Hospital's urgent and emergency care department in March. CQC found that the trust must make significant and immediate improvements, outlining areas for improvement including two breaches of legal requirements. Inspectors found a deterioration in the quality of services,...
Matched on
terms: quality, safety
CQC enforcement action
72match
Conditions Imposed: Portsmouth Hospitals NHS Trust
The Care Quality Commission issued a Warning Notice to Portsmouth Hospitals NHS Trust, requiring improvements in safety, patient consent, dignity and respect, safeguarding, and overall leadership. Concurrently, CQC placed six conditions on the trust's registration, mandating specific actions to ensure patient safety. These actions followed inspections that identified concerns in medical care services, particularly for frail older people...
Matched on
terms: quality, safety
CQC enforcement action
72match
Warning Notice: Sheffield Teaching Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Sheffield Teaching Hospitals NHS Foundation Trust following an inspection in October and November. The inspection found deterioration in the quality of services, leading to the trust's overall rating dropping to 'requires improvement' and the safe key question rated 'inadequate'. The warning notice requires the trust to take action...
Matched on
terms: quality, safety
CQC enforcement action
72match
Warning Notice: Royal Cornwall Hospitals NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Royal Cornwall Hospitals NHS Trust following an announced inspection in December. The inspection assessed actions taken after seven 'never events' occurred within the trust's surgical care group and emergency department. The warning notice required the trust to make significant improvements to the quality of healthcare, including ensuring staff...
Matched on
terms: quality, safety
Inquiry recommendation
70match
31 - Prevent in-service failure of train-borne safety equipment
Efforts should be concentrated on ensuring that AWS and other train-borne safety equipment does not fail in service through preventable causes. This should include regular replacements of equipment, maintenance of full service records and provision for full traceability of repairable parts and components (para 15.8).
Matched on
terms: safety
Committee recommendation
69match
#19 - 4th Report - Homecare medicines services: an opportunity lost
The regulatory model for homecare is failing to ensure the safety and quality of patient care. The regulators appear to have a limited understanding of the sector and there appears to be no appetite to find more information. Enforcement action taken against providers, even where avoidable harm has taken place, is feeble. There appears to be no appetite...
Matched on
terms: quality, safety
HSSIB recommendation
69match
Delays to intrapartum intervention once fetal compromise is suspected
It is recommended that the Care Quality Commission, in collaboration with relevant stakeholders, includes assessment of relational aspects such as multidisciplinary teamwork and psychological safety in its regulation of maternity units.
Matched on
terms: quality, safety
GIRFT recommendation
69match
Stroke
Formalise the ISDN assurance process for quality of SSNAP data entry and performance. There should be regular meetings between clinical and coding teams to ensure alignment with HES data and SSNAP. a) Establish quarterly independent verification of SSNAP attainment score via independent assessors. b) Stroke teams and coding teams to engage in continuous review of the coding of...
Matched on
terms: quality
GIRFT recommendation
69match
Pathology
Establish the Clean Framework as the governing ethos, overarching quality framework, and basis of pathology accreditation throughout the healthcare system. a UK Accreditation Service (UKAS) to work with the pathology community to redevelop accreditation using the Clean Framework as the basis of engagement with the ISO standard, with oversight from the National Pathology Board (NPB). b To deliver...
Matched on
terms: oversight, quality
CQC enforcement action
69match
Warning Notice: Tees, Esk and Wear Valleys NHS Foundation Trust
The Care Quality Commission (CQC) conducted an inspection of inpatient wards for people with a learning disability or autistic people at Lanchester Road Hospital and Bankfields Court, operated by Tees, Esk and Wear Valleys NHS Foundation Trust. Following the inspection, CQC told the trust to make improvements due to a significant deterioration in standards of care, concerns about...
Matched on
terms: quality
CQC enforcement action
69match
Conditions Imposed: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission imposed conditions on Greater Manchester Mental Health NHS Foundation Trust following an unannounced inspection in March 2024. The conditions require the trust to make improvements in specific areas, including effective service management, ensuring a clean, smoke-free environment with suitable cleaning rotas, and providing staff with access to up-to-date ligature risk assessments.
Matched on
terms: quality
CQC enforcement action
69match
Conditions Imposed: Mid and South Essex NHS Foundation Trust
The Care Quality Commission (CQC) placed conditions on Basildon University Hospital’s registration following inspections of its medical care and urgent and emergency services between December 2024 and March 2025. CQC found serious overcrowding in the emergency department, risking people’s safety, and identified issues with disjointed leadership, insufficient staff, and poor environmental conditions. The conditions require leaders to act...
Matched on
terms: quality, safety
CQC enforcement action
69match
Urgent Enforcement Action: Sheffield Teaching Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) took urgent action following an unannounced focused inspection of maternity services at the Jessop Wing. Urgent conditions were imposed on the trust requiring them to take action to ensure the safety of patients using these services and to regularly report to CQC on the progress made. Inspectors found a service that was not...
Matched on
terms: quality, safety
CQC enforcement action
68match
Warning Notice: County Durham and Darlington NHS Foundation Trust
CQC has told County Durham and Darlington NHS Foundation Trust that it must make immediate improvements to the quality and safety of care it’s providing, and has downgraded its well-led rating from good to inadequate following an inspection from 2 to 4 December. During this well-led inspection, CQC found the trust was in breach of regulations relating to...
Matched on
terms: quality, safety
Inquiry recommendation
66match
14 - National procedures on failure of train-borne safety equipment
Clear procedures for steps to be taken on failure of any train-borne safety equipment should apply nationally, subject only to such company variation as is fully justified (para 15.11).
Matched on
terms: safety
HSSIB recommendation
66match
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It may be beneficial to evaluate the change in organisational risk tolerance to consider the potential future impact on NHS governance and regulation processes.
Matched on
terms: safety
PFD report
65match
David Sketchley
The report identifies concerns regarding the quality of the BUPA investigation, which did not conclude on supervision levels or commode suitability. It also notes an absence of evidence that BUPA's practice reflects care service standards for commode assessments.
Matched on
terms: quality
HSSIB recommendation
65match
Potential under-recognised risk of harm from the use of propranolol
It is recommended that NHS England/NHS Improvement evaluates current approaches to the clinical oversight of overdose calls within ambulance control rooms and leads on work to develop a national framework to describe the requirements for appropriate clinical oversight of overdose calls.
Matched on
terms: oversight
GIRFT recommendation
65match
Rheumatology
People with rare RMDs should have rapid access to specialist expertise and effective treatments to ensure equity of outcomes regardless of geography and reduce the risks of morbidity and mortality. a Identify responsible clinicians and lead nurses/allied health professionals in each trust offering care for rare RMDs, to co-ordinate care for each main category of specialised rheumatology: connective...
Matched on
terms: quality
CQC enforcement action
65match
Warning Notice: Nottinghamshire Healthcare NHS Foundation Trust
The Care Quality Commission (CQC) issued requirement notices to Nottinghamshire Healthcare NHS Foundation Trust following inspections from October to December last year. CQC found improvements were needed in the trust's acute wards for adults of working age and psychiatric intensive care units, and wards for older people with mental health problems, leading to two services being rated inadequate....
Matched on
terms: quality
CQC enforcement action
65match
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) took enforcement action, serving Greater Manchester Mental Health NHS Foundation Trust with two Section 29A warning notices. One notice related to ligature and fire risks, and the other to staffing and governance, requiring significant improvements within a set timescale. CQC found a deterioration in how well-led the trust was, which was impacting the...
Matched on
terms: quality
CQC enforcement action
65match
Warning Notice: Surrey and Sussex Healthcare NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Surrey and Sussex Healthcare NHS Trust following an inspection in November last year. CQC found a breach of regulations relating to how the trust is managed and downgraded its leadership rating to requires improvement. The warning notice was issued to focus the trust's attention on making immediate improvements...
Matched on
terms: quality
CQC enforcement action
65match
Warning Notice: University Hospitals Bristol and Weston NHS Foundation Trust
The Care Quality Commission inspected the medical care services department at Weston General Hospital and found that the leadership team needed to make a number of sustainable improvements. CQC told the trust that it must send an action plan outlining the steps it will take to address concerns and make improvements.
Matched on
terms: quality