Themes | Care Quality & Organisational Culture | The Accountability Index

Quality and safety oversight

Failure to adequately assess, monitor, evaluate, and improve the quality and safety of services, hindering continuous improvement.

1,486 items 15 sources 20 inquiries
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Strongest theme matches

Mixed across source types and ranked by classifier confidence plus text match strength.

Indicative ranking
CQC action
93match
Cedar House
Must Do
Management oversight processes in place failed to establish and operate systems to ensure compliance, assess, monitor and improve the quality and safety of the service.
Matched on terms: oversight, quality, safety
CQC action
85match
Woodview House Nursing Home
Must Do
Systems and processes to ensure monitoring and oversight of the quality and safety of the service were not operating effectively.
Matched on terms: oversight, quality, safety
CQC action
83match
Continuity Healthcare Services Private Limited
Must Do
The provider had not ensured that systems or processes operated effectively to assess, monitor and improve the quality of the service and mitigate the risks relating to the health, safety and welfare of service users. The provider had not maintained accurate and complete records in respect of each service user or staff employed. The provider had not evaluated...
Matched on terms: quality, safety
CQC action
83match
Universal Care - Beaconsfield
Must Do
The provider failed to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services). The provider failed to evaluate and improve their practice in respect of the monitoring they had completed to drive forward improvements.
Matched on terms: quality, safety
CQC action
83match
Reside at Southwood
Must Do
The provider must ensure that effective systems and processes are established to assess, monitor and drive improvement in the quality and safety of services provided and that accurate records are maintained.
Matched on terms: quality, safety
CQC action
83match
Laurel Lodge Care Home
Must Do
The provider must ensure that effective governance systems are established and operated to monitor the quality of the service, identify risks to the health and safety of people, and drive continuous improvement.
Matched on terms: quality, safety
CQC action
81match
Cygnet Bury Hudson
Must Do
The provider must ensure that systems and processes operate effectively to assess, monitor and improve the quality and safety of the services provided:
Matched on terms: quality, safety
CQC action
81match
Cotton Exchange
Must Do
The provider must have systems and processes such as regular audits of the service and must assess, monitor and improve the quality and safety of the service.
Matched on terms: quality, safety
CQC action
81match
Winterton House
Must Do
Systems or processes were not established and operated effectively. Systems or processes did not enable the registered person to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity. The risks relating to the health, safety and welfare of service users and others who may be at risk...
Matched on terms: quality, safety
CQC action
81match
Verve Health
Must Do
The service must ensure governance systems and processes are in place to assess, monitor and improve the quality and safety of the service.
Matched on terms: quality, safety
CQC action
81match
Southwinds
Must Do
The provider did not have effective systems in place to assess, monitor and improve the quality and safety of the service.
Matched on terms: quality, safety
CQC action
81match
Havilah Office
Must Do
Systems or processes were not established and operated effectively to assess, monitor and improve the quality and safety of the services provided. Regulation 17 (1) (2) (a)(b)(c)
Matched on terms: quality, safety
CQC action
81match
Cary Lodge
Must Do
Systems and processes had failed to adequately assess, monitor and improve the quality and safety of people. Records were not always accurate. 17(1)(2)(a)(b)(c)
Matched on terms: quality, safety
CQC action
81match
Ashcroft House - Leeds
Must Do
The provider had not ensured systems and processes operated effectively to assess, monitor and mitigate the risks relating to the health, safety and welfare of people and to improve the quality and safety of the service provided.
Matched on terms: quality, safety
CQC action
81match
Yanah Care
Must Do
The provider must ensure effective systems and processes are in place to assess, monitor and improve the quality and safety of the services provided to people.
Matched on terms: quality, safety
CQC action
81match
Wishingwell Residential Care Home
Must Do
The provider had not established and operated effectively systems and processes to assess, monitor and improve the quality and safety of the service and to mitigate risks. Regulation 17(1).
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
Inquiry recommendation
78match
HIDD-39 - Urgently introduce independent monitoring and auditing for all safety-related work
Hidden Inquiry
BR shall introduce monitoring and independent auditing systems in all safety-related aspects of work, in particular the S&T Departments, with the greatest urgency, in advance of Total Quality Management as an aid to good management.
Matched on terms: quality, safety
Committee recommendation
78match
#7 - Implement the provisions of the Supported Housing (Regulatory Oversight) Act as quickly as possible.
Public Accounts Committee
Despite legislation designed to tackle well-established problems and gaps in regulation, MHCLG has made no progress in improving the oversight of the supported housing sector. Supported housing can provide much-needed homes for people transitioning from homelessness, or may stop people from becoming homeless in the first place. But this Committee has previously expressed concerns that gaps in regulation...
Matched on terms: oversight, quality
CQC action
77match
Valewood House Nursing Home
Must Do
People were not protected against the risks of inappropriate or unsafe care and treatment by means of the effective operation of systems designed to regularly assess and monitor the quality of the services provided and to identify assess and manager risks relating to people’s health welfare and safety.
Matched on terms: quality, safety
CQC action
73match
Clare House Residential Home
Must Do
The provider failed to ensure that their systems and processes were effective in monitoring the quality and safety of the services being provided.
Matched on terms: quality, safety
CQC action
73match
Kingsleigh Residential
Must Do
The provider failed to operate effective systems to monitor the safety and quality of the service.
Matched on terms: quality, safety
CQC action
73match
Chiltern View
Must Do
The provider must ensure quality monitoring systems are used to identify and address shortfalls in the quality of the service, and that management oversight is effective.
Matched on terms: oversight, quality
CQC action
73match
Benedict House Nursing Home
Should Do
The provider put in place effective systems to monitor the quality and safety of the service that people receive.
Matched on terms: quality, safety
Inquiry recommendation
70match
MACP-5 - Apply OFSTED-like standards to Police Service inspections for improved quality and reporting
Macpherson Inquiry
That principles and standards similar to those of the Office for Standards in Education (OFSTED) be applied to inspections of Police Services, in order to improve standards of achievement and quality of policing through regular inspection, public reporting, and informed independent advice.
Matched on terms: quality
CQC action
69match
Chatham House
Must Do
The provider must have effective systems in place to regularly assess, monitor and improve the quality of the service and act on feedback provided by people using the service.
Matched on terms: quality
CQC action
69match
Agnes House 81
Must Do
Quality monitoring systems were not robust. There was a lack of evidence that the provider was continually evaluating the service and making the required improvements.
Matched on terms: quality
CQC action
69match
Dr French Memorial Home Limited
Must Do
Systems were either not in place or robust enough to demonstrate that the services were of good quality and safety was effectively managed. Reg 17 (1)
Matched on terms: quality, safety
CQC action
69match
Widnes Hall
Must Do
The provider must operate effective systems to ensure the safety and quality of the service.
Matched on terms: quality, safety
CQC action
69match
Westwood Care Home
Must Do
The provider had failed to ensure governance systems were effective in monitoring service quality, responding to poor quality and driving improvement.
Matched on terms: quality
PFD report
65match
Walter Gordon Powley
Oct 2013 · Leicester City & South Leicestershire
Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.
Matched on terms: oversight
Inquiry recommendation
65match
R103 - Public learning disability performance dashboard within 12 months
Muckamore Abbey Inquiry
A live dashboard of performance, quality and safety indicators within learning disabilities must be developed and made publicly available within 12 months of the publication of this report.
Matched on terms: quality, safety
Inquiry recommendation
65match
R45 - Incident trend analysis on board dashboards
Muckamore Abbey Inquiry
Incident reports of any violent or aggressive behaviour by either people with learning disabilities and autistic people or staff should be analysed and trend data reported on every HSCT Board’s quality and safety dashboard. In private and third sector care a similar system must be in place.
Matched on terms: quality, safety
Committee recommendation
65match
#20 - 79th Report - Supporting people with frailty outside hospitals
Public Accounts Committee
NHSE informed us that there are also a number of broader developments which may affect service provision for frailty including a forthcoming modern service framework, new funding models for ICBs, a frailty improvement collaborative involving seven sites around the country, the commissioning oversight framework and a refresh of the Better Care Fund.40 It is unclear when these will...
Matched on terms: oversight
CQC action
65match
Brook House Residential Home
Must Do
Improve quality monitoring systems to identify and address areas requiring improvement, including gaps in decision-making processes, medicine administration timings, and environmental challenges.
Matched on terms: quality
CQC action
65match
Haisthorpe House
Must Do
The provider must ensure people who used services are protected against the risks of inappropriate or unsafe care and treatment, by means of the effective operation of systems designed to enable the registered person to regularly assess and monitor the quality of the services provided.
Matched on terms: quality
CQC action
65match
Archers Point Residential Home
Must Do
There were not effective systems in place to assess and monitor the quality of the service provided.
Matched on terms: quality
Inquiry recommendation
62match
R44 - Proactive quality assurance beyond complaints
Muckamore Abbey Inquiry
Complaints alone are a poor indicator of quality of care, particularly in a vulnerable population such as those admitted to MAH. A low volume or absence of complaints does not necessarily indicate that care provided is good or satisfactory. Organisations must find proactive approaches to assure themselves and the public that high standards of care are being provided,...
Matched on terms: quality
Inquiry recommendation
62match
HIDD-38 - Urgently use outside consultants to review safety management and communication issues
Hidden Inquiry
The Court endorses the use of outside consultants to review safety management issues within BR and recommends that the consultants proceed with their programme with the greatest urgency looking particularly at problems of communication up and down the organisation.
Matched on terms: safety
PFD report
61match
Ben Haddon-Cave
Sep 2019 · London Inner (North)
Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection reporting, led to a lack of oversight and repair.
Matched on terms: oversight
Committee recommendation
61match
#3 - 1st Report – Employment support for disabled people: Connect to Work
Work and Pensions Committee
We welcome the programme’s devolved design and recognise the government’s view that it appropriately balances national oversight with local flexibility. We are reassured that extensive performance monitoring is part of CtW, and that there is also a comprehensive evaluation programme built into CtW from the outset, providing a mechanism not just to monitor performance and inform learning, but...
Matched on terms: oversight
Committee recommendation
61match
#12 - 79th Report - Supporting people with frailty outside hospitals
Public Accounts Committee
NHSE has set requirements for ICBs and GPs to provide health services that aim to assess and support people living with moderate and severe frailty.25 NHSE considers that ICBs are responsible for managing and measuring performance of many of the services that aim to support people living with frailty.26 NHSE told us that ICBs are responsible for commissioning...
Matched on terms: quality
CQC action
61match
Serenity House
Must Do
There was a lack of effective systems and processes in place for monitoring quality of the service.
Matched on terms: quality
CQC action
61match
Nower House
Must Do
The failure to ensure consistent management oversight of the service and respond to shortfalls in a timely manner was a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Matched on terms: oversight
CQC action
61match
Gledhow Lodge
Must Do
Quality assurance processes were not robust or effective in identifying areas of improvement and analysing records for trends and themes. Records were not always managed effectively.
Matched on terms: quality
CQC action
61match
Benthorn Lodge
Must Do
The registered person did not have an effective system in place to monitor the quality of care provided to people or to manage risks of unsafe or inappropriate treatment. There was a lack of management and leadership at the service.
Matched on terms: quality
CQC action
61match
Arthur House
Must Do
The provider did not have robust, consistent and adequate systems in place to monitor the quality of the service.
Matched on terms: quality
IOPC learning recommendation
61match
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should take steps to ensure there is effective supervision and quality assurance in place for officers where there is little measurable work output to review, to ensure the maintenance of policing standards and officers’ well-being. This follows an investigation into allegations of misconduct in a team of police officers working at Charing...
Matched on terms: quality
IOPC learning recommendation
61match
Care and attention for man whilst detained in custody – Thames Valley Police, June 2021
The IOPC recommends that Thames Valley Police ensures that the quality of the cell checks conducted by detention officers are regularly monitored by their supervisors, and any concerns are recorded and fed back to them. This follows an investigation into the death of a man at Thames Valley Police police station. The custody sergeant required the detainee to...
Matched on terms: quality
CQC action
59match
Westacre Nursing Home
Must Do
We found no evidence that people had been harmed however, there was a failure to operate effective systems to assess, monitor and improve the service.
Matched on classifier match
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