Feedback not integrated
Failure of service providers to systematically collect and integrate feedback from staff, service users, and relatives to inform improvements.
37 items
1 source
12 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
74match
R47 - Quarterly family feedback via external agency
The provider should actively seek family or carer feedback on the service user’s experience on a quarterly basis via an external agency and report the findings to the public part of a Board-level committee minutes (where these exist) and publish them on the provider’s website.
Matched on
terms: feedback
Inquiry recommendation
70match
R46 - Lived experience feedback via external agency
Where people with learning disabilities can participate, the provider should actively seek their lived experience feedback in relation to staff attitudes and behaviours on a quarterly basis through an external and independent agency (perhaps to be undertaken by the PCC), and report this to a public part of a Board-level committee and also publish it on the provider’s...
Matched on
terms: feedback
Inquiry recommendation
61match
BRIS-28 - Routinely seek, act on, and publish patient feedback and experience surveys across NHS
Patients must be given the opportunity to pass on views on the service which they have received: all parts of the NHS should routinely seek and act on feedback from patients as to their views of the service. In addition, formal, systematic structured surveys of patients’ experience of their care (not merely satisfaction surveys) should be routinely conducted...
Matched on
terms: feedback
Inquiry recommendation
56match
BRIS-166 - PCTs must involve public in commissioning hospital services and gather feedback
Primary care trusts (and groups), given their capacity to influence the quality of care in hospitals, must involve patients and the public, for example through each PCG/T’s Patient and Advocacy Liaison Service. They must make efforts systematically to gather views and feedback from patients. They must pay particular attention to involving their local community in decision-making about the...
Matched on
terms: feedback
Inquiry recommendation
52match
F198 - Measuring cultural health
Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing workplaces and teams, which build on the experience and feedback of nursing staff using a robust methodology, such as the "cultural barometer".
Matched on
terms: feedback
Inquiry recommendation
52match
F12 - Fundamental standards of behaviour
Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report they make, including information about any action taken or reasons for not acting.
Matched on
terms: feedback
Inquiry recommendation
51match
F158 - Training and training establishments as a source of safety information
The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from students and tutors on compliance by placement providers with minimum standards of patient safety and quality of care, and should generally place the highest priority on the safety of patients.
Matched on
terms: feedback
Inquiry recommendation
48match
R20 - Independent advocacy for service users and families
Properly trained independent advocates should be made available to service users and families to support effective communication with staff and for raising concerns and complaints. DoH/SPPG should specify the level of advocacy services required for people with learning disabilities in the annual commissioning plan.
Matched on
classifier match
Inquiry recommendation
47match
F159 - Training and training establishments as a source of safety information
Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards of care provided to patients. The General Medical Council should consult the Care Quality Commission in developing the survey and routinely share information obtained with healthcare regulators.
Matched on
terms: feedback
Inquiry recommendation
45match
R38 - Clear pathways for raising concerns
People with learning disabilities and autistic people and their families should be provided with clear, written information outlining the available pathways for raising concerns. This information should clearly distinguish between an enquiry, a concern and a complaint. Individuals should then be asked to select the option that they feel best aligns with their needs. This selection should be...
Matched on
classifier match
Inquiry recommendation
44match
AFA-1 - Patient focus and complaints
The Inquiry recommends that the Trust and Department work together to ensure there is: • A specific programme of work to strengthen patient involvement, improve communication, and ensure patients and families are treated as partners in care. • Direct communication with patients as standard practice. • More effective handling of concerns and complaints, with an emphasis on early...
Matched on
classifier match
Inquiry recommendation
44match
HIDD-52 - Provide appropriate feedback to drivers reporting signalling irregularities on outcomes
BR shall ensure that drivers, reporting on signalling irregularities, are given appropriate feedback on the outcome.
Matched on
terms: feedback
Inquiry recommendation
41match
R39 - Guidance on recording and presenting concerns
People with learning disabilities and autistic people and their families should be provided with a short description of how best to record and present concerns so as to be effective.
Matched on
classifier match
Inquiry recommendation
40match
RHI-35 - Early Warning Systems
Better systems are needed for spotting early warnings and concerns from the public and businesses that something unexpected could be happening or going wrong with an initiative. Simply updating existing complaints and whistle-blowing policies, although helpful, will not be sufficient, since relevant intelligence often does not come through these routes. The default response amongst officials should be one...
Matched on
classifier match
Inquiry recommendation
39match
13 - Improve complaints handling
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in responding to complaints, and introduce measures to promote the use of complaints as a source of improvement and reduce defensive 'closed' responses to complainants. The Trust should increase public and patient involvement in resolving complaints, in the case of maternity...
Matched on
classifier match
Inquiry recommendation
39match
24 - Involve patients and relatives in incident investigation
We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious incidents, both to provide evidence that may otherwise be lacking and to receive personal feedback on the results. Action: the Care Quality Commission, NHS England.
Matched on
terms: feedback
Inquiry recommendation
36match
F113 - Complaints handling
The recommendations and standards suggested in the Patients Association's peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be reviewed and implemented in the NHS.
Matched on
classifier match
Inquiry recommendation
36match
IBI-A-2e - Transparency of Scheme Design
The Government and IBCA establish a mechanism by which individuals or organisations may raise concerns which arise about any aspect of the scheme which from time to time is troubling them. The mechanism is intended to help continuous improvement of, and/or aid understanding of, any aspect of the scheme. It should involve identifying a person or body to...
Matched on
classifier match
Inquiry recommendation
35match
F151 - Complaints to MPs
MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns of wider significance than the impact on one individual patient.
Matched on
classifier match
Inquiry recommendation
32match
R78 - Audit committee implementation tracking
HSCT Board audit committees should consider all internal audit recommendations and require directorates to provide updates on implementation three months, six months and one year after the internal audit report is received, and three monthly thereafter if still not fully implemented.
Matched on
classifier match
Inquiry recommendation
32match
AC-2d - Structured Response to Community Input
To build confidence that IBCA is actively listening to people infected and affected, IBCA adopt more of a structured response to contributions from people infected and affected. Consideration should be given, as a minimum, to making a contemporaneous record of IBCA's understanding of the matters that had been raised in meetings with people infected and affected and setting...
Matched on
classifier match
Inquiry recommendation
32match
MAI-112 - Give consideration to NHS commissioner recommendations
The Department of Health and Social Care should give urgent and close consideration to any recommendations made by the trusts and the NHS commissioners.
Matched on
classifier match
Inquiry recommendation
31match
LADB-17 - Develop a blame-free culture for safety information communication in industry
The development of a culture within the industry in which information is communicated without fear of recrimination, and blame is attached only where this is justified, is commended (para 9.60).
Matched on
classifier match
Inquiry recommendation
27match
IBI-10a(v) - Yellow Card System Prominence
Steps be taken to give greater prominence to the online Yellow Card system to those receiving drugs or biological products, or who are being transfused with blood components.
Matched on
classifier match
Inquiry recommendation
27match
LADB-89 - HSC to review compliance with recommendations and publish review outcomes.
A review of compliance with the above recommendations should be conducted on behalf of the HSC within six months of publication of this report, and further reviews should be put in hand as necessary thereafter. The HSC should publish the outcome of such reviews (para 15.7).
Matched on
classifier match
Inquiry recommendation
27match
BRIS-165 - NHS Modernisation Agency to advise on achieving widest public and patient involvement
The involvement of the public, particularly of patients, should not be limited to the representatives of patients’ groups, or to those representing the interests of patients with a particular illness or condition: the NHS Modernisation Agency should advise the NHS on how to achieve the widest possible involvement of patients and the public in the NHS at local...
Matched on
classifier match
Inquiry recommendation
27match
BRIS-164 - Provide financial resources to support public involvement, covering costs like childcare
Financial resources must be made available to enable members of the public to become involved in NHS organisations: this should include provision for payments to cover, for example, the costs of childcare, or loss of earnings.
Matched on
classifier match
Inquiry recommendation
27match
BRIS-163 - Provide training and guidance to properly support public involvement processes
The process of public involvement must be properly supported, through for example, the provision of training and guidance.
Matched on
classifier match
Inquiry recommendation
27match
BAHA-46 - Lessons Learned Process
The MoD should consider whether the lessons learned procedures need to be adjusted or supplemented so that the clearer and more urgent lessons and changes to previous practice are fed back far more quickly both to the operational theatre and into the pre-deployment training cycle.
Matched on
classifier match
Inquiry recommendation
27match
IBI-10a(i) - Patient Satisfaction in Clinical Audits
A clinical audit should as a matter of routine include measures of patient satisfaction or concern, and these should be reported to the board of the body concerned. Success in this will be measured by comparing the measure of satisfaction from one year to the next, such that the reports to the board concerned demonstrate a trend of...
Matched on
classifier match
Inquiry recommendation
23match
AC-2c - Community Advisory Body
A formal role be given within IBCA for an advisory body consisting of people infected and affected, covering a range of experience broadly representative of those groups, and (if those groups so wish) including clinicians covering the major relevant disciplines of hepatitis and liver disease, HIV, transfusion, haemophilia, psychosocial aspects and palliative care. The advisory body should choose...
Matched on
classifier match
Inquiry recommendation
23match
IBI-9b - Trust/Board Action on Peer Reviews
That NHS Trusts and Health Boards should be required to deliberate on peer review findings and give favourable consideration to implementing the changes identified with a view to ensuring comprehensive, safe, care.
Matched on
classifier match
Inquiry recommendation
23match
IBI-7e - Implementing SHOT Reports
Implementing SHOT reports: That all NHS organisations across the UK have a mechanism in place for implementing recommendations of Serious Hazard of Transfusion (SHOT) reports, which should be professionally mandated, and for monitoring such implementation.
Matched on
classifier match
Inquiry recommendation
22match
BRIS-31 - Require trusts to publish periodic reports on patient views and actions
Trusts and primary care trusts must have systems for publishing periodic reports on patients’ views and suggestions, including information about the action taken in the light of them. (See further the Recommendations on care of an appropriate standard.)
Matched on
classifier match
Inquiry recommendation
18match
IBI-2b - Treloar's School Memorial
A memorial be established at public expense, dedicated specifically to the children infected at Treloar’s school. The memorial should be such as is agreed with those who were pupils at Treloar’s.
Matched on
classifier match
Inquiry recommendation
18match
IBI-2a - UK and Devolved Memorials
A permanent memorial be established in the UK and consideration be given to memorials in each of Northern Ireland, Wales and Scotland. The nature of the memorial(s), their design and location should be determined by a memorial committee consisting of people infected and affected and representatives of the governments. It should be funded by the UK government.
Matched on
classifier match
Inquiry recommendation
14match
HIA-2 - Memorial at Stormont
We recommend that a suitable physical memorial should be erected in Parliament Buildings, or in the grounds of the Stormont Estate.
Matched on
classifier match