Patient safety governance
Lack of well-protected and defined resources for national patient safety agencies and insufficient awareness among healthcare professionals of the Duty of Candour.
293 items
1 source
13 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
87match
F41 - Use of information about compliance by regulator from: Patient safety alerts
The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement them. Information-sharing with the Care Quality Commission regarding patient safety alerts should continue following the transfer of the National Patient Safety Agency's functions in June 2012 to the...
Matched on
terms: patient, safety
Inquiry recommendation
86match
AFA-4 - Governance
The Inquiry recommends a programme of work by the Trust to: • Consolidate governance improvements into a clear, prioritised programme overseen by the Board. This will ensure that the large number of improvement plans do not become overwhelming or get lost due to time pressure. • Develop a comprehensive data and information strategy to support assurance, learning and...
Matched on
terms: governance, patient, safety
Inquiry recommendation
77match
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: governance, patient, safety
Inquiry recommendation
73match
AFA-2 - Organisational development and cultural reform
The Inquiry recommends that: • The Department should continue to emphasise the importance of cultural change as shown in current work and formally recognise that this contributes to a system wide focus on patient safety as a core system aim. Devising a Northern Ireland patient safety strategy would consolidate and clarify the various strands of work in progress....
Matched on
terms: patient, safety
Inquiry recommendation
65match
F32 - Interim measures
Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take whatever action within their powers is necessary to protect patient safety. Such action should include, where necessary, temporary measures to ensure such protection while any investigation required to make a final determination is undertaken.
Matched on
terms: patient, safety
Inquiry recommendation
62match
R81 - Expert clinical governance advisory function
The DoH should establish an expert clinical/social governance advisory function to support providers.
Matched on
terms: governance
Inquiry recommendation
62match
R77 - Triennial Board governance reviews
The DoH Permanent Secretary should commission triennial reviews of each Board’s collective performance in clinical and social care governance.
Matched on
terms: governance
Inquiry recommendation
62match
R76 - NED with clinical governance expertise
NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical or social care governance and be appointed as a senior independent director with that responsibility. The DoH should make training in Board-level clinical and social governance available to all NEDs.
Matched on
terms: governance
Inquiry recommendation
62match
R75 - Executive Director of Clinical and Social Care Governance
There must be understanding of both individual untoward events but also (and more importantly) systems and trends. Creating and maintaining effective governance for complex systems requires specialist skills. While this is largely recognised within finance governance, only superficial consideration is given to clinical and social care governance. Boards should appoint an Executive Director of Clinical and Social Care...
Matched on
terms: governance
Inquiry recommendation
62match
F62 - Improved patient focus
For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into its own structures, to ensure this focus is always at the forefront of its work.
Matched on
terms: patient
Inquiry recommendation
61match
F59 - Care Quality Commission independence strategy and culture
Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of nursing and allied healthcare professionals, and patient representative groups.
Matched on
terms: patient
Inquiry recommendation
60match
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: patient, safety
Inquiry recommendation
57match
F67 - Focus on compliance with fundamental standards
The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for foundation trust status. The assessment must include as a priority focus a review of the standard of service delivered to patients, and the sustainability of a service at the required standard.
Matched on
terms: patient
Inquiry recommendation
57match
F60 - Consolidation of regulatory functions
The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to the Care Quality Commission.
Matched on
terms: governance
Inquiry recommendation
57match
F37 - Use of information about compliance by regulator from: Quality accounts
Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each standard which applies to them. To the extent that it is not practical in a written report to set out detail, this should be made available via each trust's website. Reports should no longer be confined...
Matched on
terms: safety
Inquiry recommendation
53match
F68 - Focus on compliance with fundamental standards
No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager (the Strategic Health Authority cluster, the Department of Health team, or the NHS Trust Development Authority) is satisfied that the organisation currently meets Monitor's criteria for authorisation and that it is delivering a sustainable service which...
Matched on
terms: patient
Inquiry recommendation
53match
F58 - Care Quality Commission independence strategy and culture
Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients' consultative council with which issues could be discussed to obtain a patient perspective directly.
Matched on
terms: patient
Inquiry recommendation
53match
F36 - Use of information for effective regulation
A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in as near real time as possible, and should be capable of use by regulators in assessing the risk of non-compliance. It must not only include statistics about outcomes, but must take advantage of all safety related...
Matched on
terms: safety
Inquiry recommendation
53match
F5 - Clarity of values and principles
In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that: Staff put patients before themselves; They will do everything in their power to protect patients from avoidable harm; They will be honest and open with patients regardless of the consequences for themselves; Where they are unable to provide the assistance a...
Matched on
terms: patient
Inquiry recommendation
53match
F4 - Clarity of values and principles
The core values expressed in the NHS Constitution should be given priority of place and the overriding value should be that patients are put first, and everything done by the NHS and everyone associated with it should be informed by this ethos.
Matched on
terms: patient
Inquiry recommendation
45match
F61 - Consolidation of regulatory functions
A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such a move should not be used as a justification for reduction of the resources allocated to this area of regulatory activity. It would be vital to retain the corporate memory of both organisations.
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classifier match
Inquiry recommendation
45match
F54 - Care Quality Commission independence strategy and culture
Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to avoid any suggestion of inappropriate interference in the Care Quality Commission's statutory role.
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classifier match
Inquiry recommendation
45match
F52 - Enhancement of monitoring and the importance of inspection
The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage of any peer review arrangements available.
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classifier match
Inquiry recommendation
45match
F51 - Enhancement of monitoring and the importance of inspection
The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of NHS hospital care providers should be led by such inspectors who should have the support of a team, including service user representatives, clinicians and any other specialism necessary because of particular concerns. Consideration should be given...
Matched on
classifier match
Inquiry recommendation
45match
F47 - Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees
The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. For example, it should further develop its current 'sounding board events'.
Matched on
classifier match
Inquiry recommendation
45match
F45 - Use of information about compliance by regulator from: Inquests
The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.
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classifier match
Inquiry recommendation
45match
F43 - Use of information about compliance by regulator from: Media
Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility.
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classifier match
Inquiry recommendation
45match
F40 - Use of information about compliance by regulator from: Complaints
It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the numbers.
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classifier match
Inquiry recommendation
45match
F33 - Interim measures
Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the necessary amendments to legislation to provide such powers.
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classifier match
Inquiry recommendation
41match
F66 - Improving contribution of stakeholder opinions
The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to ensuring that: Local stakeholder and public opinion is sought on the fitness of a potential applicant NHS trust for foundation trust status and in particular on whether a potential applicant is delivering a sustainable service compliant...
Matched on
classifier match
Inquiry recommendation
41match
F65 - Quality of care as a pre-condition for foundation trust applications
The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of care as a pre-condition to consideration for support for a foundation trust application.
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classifier match
Inquiry recommendation
41match
F64 - Authorisation of foundation trusts
The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this effectively. With due regard to protecting the public from the adverse consequences inherent to any reorganisation, the regulation of the authorisation process and compliance with foundation trust standards should be transferred to the Care Quality Commission,...
Matched on
classifier match
Inquiry recommendation
41match
F63 - Improved transparency
Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.
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classifier match
Inquiry recommendation
41match
F57 - Care Quality Commission independence strategy and culture
The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the Trust described in this report, and in the report of the first inquiry, and open that evaluation for public scrutiny.
Matched on
classifier match
Inquiry recommendation
41match
F56 - Care Quality Commission independence strategy and culture
The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, with a degree of clarity that may have been missing to date.
Matched on
classifier match
Inquiry recommendation
41match
F55 - Care Quality Commission independence strategy and culture
The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and enforcement effectively, in accordance with the principles outlined in this report.
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classifier match
Inquiry recommendation
41match
F53 - Care Quality Commission independence strategy and culture
Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a new one must be avoided.
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classifier match
Inquiry recommendation
41match
F50 - Enhancement of monitoring and the importance of inspection
The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.
Matched on
classifier match
Inquiry recommendation
41match
F49 - Enhancement of monitoring and the importance of inspection
Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring in relation to the value to be obtained from: The Quality and Risk Profile; Quality Accounts; Reports from Local Healthwatch; New or existing peer review schemes; Themed inspections.
Matched on
classifier match
Inquiry recommendation
41match
F48 - Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees
The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to the Care Quality Commission.
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classifier match
Inquiry recommendation
41match
F46 - Use of information about compliance by regulator from: Quality and risk profiles
The Quality and Risk Profile should not be regarded as a potential substitute for active regulatory oversight by inspectors. It is important that this is explained carefully and clearly as and when the public are given access to the information.
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classifier match
Inquiry recommendation
41match
F44 - Use of information about compliance by regulator from: Media
Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for the trust concerned to demonstrate that the learning to be derived has been successfully implemented.
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classifier match
Inquiry recommendation
41match
F42 - Use of information about compliance by regulator from: Serious untoward incidents
Strategic Health Authorities/their successors should, as a matter of routine, share information on serious untoward incidents with the Care Quality Commission.
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classifier match
Inquiry recommendation
41match
F39 - Use of information about compliance by regulator from: Complaints
The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.
Matched on
classifier match
Inquiry recommendation
41match
F38 - Use of information about compliance by regulator from: Complaints
The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant to assessment of compliance with fundamental standards, and should actively seek this information out, probably via its local relationship managers. Any bureaucratic or legal obstacles to this should be removed.
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classifier match
Inquiry recommendation
41match
F35 - Need to share information between regulators
Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all intelligence which when pieced together with that possessed by partner organisations may raise the level of concern. Work should be done on a template of the sort of information each organisation would find helpful.
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classifier match
Inquiry recommendation
41match
F34 - Interim measures
Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim arrangements for protecting the public.
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classifier match
Inquiry recommendation
41match
F6 - Clarity of values and principles
The handbook to the NHS Constitution should be revised to include a much more prominent reference to the NHS values and their significance.
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classifier match
Inquiry recommendation
36match
R12 - Single written channel for serious incident reports
We recommend that reports of serious untoward incidents to District and Regional Health Authorities should be made in writing and through a single channel which is known to all involved (para 5.4.12)
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classifier match
Inquiry recommendation
36match
R11 - Incident report on monitoring alarm failure
We recommend that in the event of failure of an alarm on monitoring equipment, an untoward incident report should be completed and the equipment serviced before it is used again (para 5.11.6).
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classifier match