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
Inquiry recommendation
89match
AFA-7B - Cancer Services
The Trust has worked through a detailed action plan relating to Cancer Services, specifically in relation to the oversight and support for MDTs and has addressed the issues identified in the SAIs in urology. Extending the work to include dimensions of quality, safety and strategic planning in Cancer Services would be of benefit. The Trust has understood the...
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
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
The County Hospital
The provider must ensure there are systems and processes to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activities. It must assess, monitor and mitigate the risks relating to the health, safety and welfare of patients and others who may be at risk which arise from the...
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
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
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
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
Inquiry recommendation
70match
MACP-5 - Apply OFSTED-like standards to Police Service inspections for improved quality and reporting
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
Inquiry recommendation
69match
AFA-7A - Urology Service
The impact of the Inquiry on the Urology Department has been very significant. The Inquiry recommends that the Urology Service be provided with ongoing specific medical and operational leadership support from Senior Management, the Board and the Department. This will allow for stabilisation and help to rebuild the confidence of patients, the public and staff. The Inquiry considers...
Matched on
terms: quality
Inquiry recommendation
69match
AFA-6 - Medical leadership and doctors in difficulty
The Inquiry recommends that: • There must be sustained investment in leadership development for doctors at all career stages. Improvements discussed in the Medical Management and Leadership chapter should continue. The Department should establish a dedicated regional programme to strengthen medical leadership and management. This programme should focus on all aspects of medical management and leadership; aid continuous...
Matched on
terms: oversight
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
CQC action
69match
The Tunbridge Wells Hospital at Pembury
The service must ensure there are effective governance systems and processes to identify and manage incidents, risks, issues and performance and to monitor progress through completion of audits, action plans and oversight of improvements and reduce the recurrence of incidents and harm.
Matched on
terms: oversight
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
Walter Gordon Powley
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
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
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
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
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
Inquiry recommendation
62match
R44 - Proactive quality assurance beyond complaints
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
PFD report
61match
Ben Haddon-Cave
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
Inquiry recommendation
61match
AFA-3 - Board and senior leadership development
The Inquiry recommends: • The Department implements and funds a bespoke, regional leadership development programme for Board members and senior leaders, co-designed with external expertise including specific training in patient safety. This will complement the recently updated Board Handbook which provides excellent guidance and, if used as intended, should provide the basis for an effective Board. Such a...
Matched on
terms: safety
Committee recommendation
61match
#3 - 1st Report – Employment support for disabled people: Connect to Work
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
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
HSSIB recommendation
61match
Failures in communication or follow-up of unexpected significant radiological findings
It is recommended that the Care Quality Commission amends all appropriate core service frameworks to include risk controls identified in this report, to mitigate the risk of significant abnormal findings not being followed up.
Matched on
terms: quality
HSSIB recommendation
61match
The diagnosis of ectopic pregnancy
It is recommended that the Care Quality Commission Services Framework for Gynaecology and Termination Services includes an assessment of early pregnancy services, using as a reference the National Institute for Health and Care Excellence Guideline 126, Ectopic pregnancy and miscarriage: diagnosis and initial management.
Matched on
terms: quality
HSSIB recommendation
61match
Placement of nasogastric tubes
It may be beneficial if national organisations including the Medicines and Healthcare products Regulatory Agency, NHS Supply Chain and NHS England and NHS Improvement review arrangements for ensuring all medical device related incidents, Yellow Card reports, or other device safety related information, including any involving concerns with pH or X-ray in the context of nasogastric tubes, are shared...
Matched on
terms: safety
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
Scottish FAI
61match
Andrezej Freitag
I urge that there be improvements in the certification of competent staff and the policing of health and safety legislation.
Matched on
terms: safety
PHSO casework decision
60match
P-003487 - Care Quality Commission
Mrs X, on behalf of staff, complained about the CQC Inspector's unprofessional attitude and behaviour during an inspection, which negatively impacted staff confidence and sought service improvements.
Matched on
terms: quality
PFD report
57match
Martyn Watkins
Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and facility safety on Aspen Ward are identified and addressed.
Matched on
terms: safety
PFD report
57match
Neville Welton
The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.
Matched on
terms: safety
PFD report
57match
Margaret Evans
Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.
Matched on
terms: safety
PFD report
57match
Sophie Bennett
The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.
Matched on
terms: oversight
PFD report
57match
Kathleen Smith
Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.
Matched on
terms: oversight
PHSO casework decision
57match
P-003058 - Care Quality Commission
Mr and Mrs B complained the CQC failed to properly inspect a nursing home, act on intelligence, communicate effectively, follow enforcement policy, and resolve their complaints, causing distress.
Matched on
terms: quality
Inquiry recommendation
57match
64 - Welsh independent school standards update
The Welsh Government should: update the Independent School Standards as a matter of urgency; update the national minimum standards for boarding schools as a matter of urgency; legislate so that all residential special schools are judged against the quality standards in place for care homes in Wales; ensure that all teachers and learning support staff in independent schools...
Matched on
terms: quality
Inquiry recommendation
57match
58 - Residential schools inspection and guardians registration
The Department for Education and the Welsh Government should: require all residential special schools to be inspected against the quality standards used to regulate children's homes in England and care homes in Wales; reintroduce a duty on boarding schools and residential special schools to inform the relevant inspectorate of allegations of child sexual abuse and other serious incidents,...
Matched on
terms: quality
Inquiry recommendation
57match
R79 - Board member learning framework
The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should be required to undertake an examined course in governance (including both financial and clinical/social care governance, including patient safety). Annual assessments as to the effectiveness of Board performance should be undertaken by PHA.
Matched on
terms: safety
Inquiry recommendation
57match
R32 - Balanced performance measures including restrictive practices
HSCTs should implement a comprehensive set of balanced performance measures across all services for people with learning disabilities, including those commissioned from third-party providers. These measures should include: Trends in the use of restrictive practices; Trends of aggressive behaviour incidents, including peer-on-peer aggression and patient-on-staff aggression; Positive experience, including quality of life measures.
Matched on
terms: quality
Committee recommendation
57match
#14 - 79th Report - Supporting people with frailty outside hospitals
NHSE also told us that it was about to write to ICBs, as part of the framework for neighbourhood health, with the key requirements that ICBs need to have in place next year around enabling better, more appropriate care for the moderately and severely frail population. NHSE also agreed that oversight would be a bigger challenge for ICBs...
Matched on
terms: oversight
Committee recommendation
57match
#6 - 79th Report - Supporting people with frailty outside hospitals
We remain deeply concerned that cuts to ICBs are insufficiently thought through and will undermine their ability and capacity to carry out their functions. It is unclear what oversight roles ICBs will retain under NHSE’s plans to make them into strategic commissioners. On 1 April 2025, NHSE announced that ICBs had to make 50% cost reductions. To achieve...
Matched on
terms: oversight
HSSIB recommendation
57match
Patient care in temporary care environments
NHS regional and national organisations can improve patient safety by enhancing understanding of the use of temporary care environments across all hospital settings. This may include agreeing definitions of temporary care environments and enhanced information gathering on their use and impact on patient safety.
Matched on
terms: safety
HSSIB recommendation
57match
Medication related harm
HSSIB recommends that NHS England/Department of Health and Social Care develops an external assurance framework for information standards notices relating to electronic prescribing and medicines administration (ePMA). This is to reduce unwarranted variation and improve patient safety through expert-led assurance processes.
Matched on
terms: safety
HSSIB recommendation
57match
Transition from child and adolescent mental health services to adult mental health services
It is recommended that the Care Quality Commission (CQC) extends the remit of its inspections to ensure that the whole care pathway, from child and adolescent mental health services to adult mental health services, is examined.
Matched on
terms: quality
CQC action
57match
Stroud Maternity Hospital
The service must ensure they have regular audit to demonstrate compliance with standards and procedures, to identify gaps, implement and monitor improvement Regulation 17(1)(2)(a)(b).
Matched on
classifier match