Quality and safety oversight
Failure to adequately assess, monitor, evaluate, and improve the quality and safety of services, hindering continuous improvement.
440 items
1 source
21 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
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
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
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
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
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
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
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
Inquiry recommendation
53match
47 - Catholic lead clergy for safeguarding
The Catholic Bishops' Conference of England and Wales and the Conference of Religious in England and in Wales should each nominate a lead member of the clergy for safeguarding to provide leadership and oversight on safeguarding matters to their respective Conferences and the wider Roman Catholic Church in England and in Wales.
Matched on
terms: oversight
Inquiry recommendation
53match
R67 - Independent review of systemic abuse conditions
Where there is evidence or suspicion of widespread abuse involving multiple staff and residents, focusing solely on individual perpetrators is insufficient. An independent review of enabling conditions should be conducted separately from case-specific or PSNI investigations. This review must be led by investigators with appropriate expertise in safety science to support rapid system-level changes. PHA, in conjunction with...
Matched on
terms: safety
Inquiry recommendation
53match
R33 - Statistical process control charts
To ensure meaningful interpretation of these trends, all HSCTs should adopt statistical process control (SPC) charts, as developed by Walter Shewhart in 1939. SPC charts use calculated upper and lower control limits to distinguish between normal variation in a stable process and significant long-term shifts in performance. These charts provide a clear visual flag as to when further...
Matched on
classifier match
Inquiry recommendation
53match
R15 - Independent care plan reviews
Care plans should be regularly evaluated to assess their impact on people’s wellbeing. This is the responsibility of the care team and should include formal, documented input from the service user themselves (where appropriate) and families. Additionally, there should be regular independent reviews overseen by the Public Health Agency (PHA) to assess any deviation from best practice, both...
Matched on
classifier match
Inquiry recommendation
49match
FR-2 - Child Protection Authorities
The Inquiry recommends that the UK government establishes a Child Protection Authority for England and the Welsh Government establishes a Child Protection Authority for Wales. Each Authority's purpose should be to: improve practice in child protection; provide advice and make recommendations to government in relation to child protection policy and reform to improve child protection; and inspect institutions...
Matched on
classifier match
Inquiry recommendation
49match
R28 - Restraint Reduction Network principles
The Restraint Reduction Network identifies six principles to avoid the use of restrictive practice. While there is evidence that some Trusts have adopted these principles, further action is needed to ensure the principles are fully embedded. These principles must be embedded in policies and practices. The principles are: i. Organisational commitment – led by executive directors ii. Performance...
Matched on
classifier match
Inquiry recommendation
49match
R1 - Implementation monitoring group
The implementation of the following recommendations should be monitored by the DoH and progress should be reported to the DoH Permanent Secretary. To ensure progress is made, an implementation consultation group, which should include service users and the relatives of service users, should be created and be involved in the monitoring and reporting process.
Matched on
classifier match
Inquiry recommendation
45match
50 - Independent validation of Catholic audit programme
The Catholic Safeguarding Advisory Service should have the effectiveness of its audit programme regularly validated by an independent organisation which is external to the Church. These independent reports should be published.
Matched on
classifier match
Inquiry recommendation
45match
7 - Catholic complaints policy with escalation process
The Catholic Bishops' Conference of England and Wales and the Conference of Religious should publish a national policy for complaints about the way in which a safeguarding case is handled. The policy should deal with communication with complainants during the complaints process and set out an escalation process for all complainants to have their complaint assessed by an...
Matched on
classifier match
Inquiry recommendation
45match
R84 - Learning disability service culture measure
RQIA needs to consider adopting a measure of service culture specific to learning disability services for use in its inspections. Such measures have already been developed for learning disability residential settings.
Matched on
classifier match
Inquiry recommendation
45match
R83 - RQIA use of CCTV in inspections
The RQIA needs to reconsider whether to make use of CCTV when it is in operation in a service it is inspecting where concerns have been raised.
Matched on
classifier match
Inquiry recommendation
45match
R82 - Risk-based inspection prediction
RQIA should consider developing a risk-based way of predicting which services are in difficulty. It is well known that certain aspects of services tend to be associated with abuse: service users who are vulnerable, who have few communication skills; service users with behaviour that challenges; services with poorly trained staff, insufficient staff, poor staff management, high sickness levels...
Matched on
classifier match
Inquiry recommendation
45match
R62 - Monthly safeguarding dashboard
Metrics on both child and adult safeguarding processes should be reported monthly via a safeguarding dashboard, with the same visibility and status as monitoring elective surgery or emergency department waiting times. These metrics should be publicly available.
Matched on
classifier match
Inquiry recommendation
45match
R48 - Holistic safeguarding governance review
HSCTs must review and improve governance of safeguarding to ensure that findings from different safeguarding investigations are considered holistically, synthesised and presented to the public part of a Board-level committee.
Matched on
classifier match
Inquiry recommendation
45match
R36 - Seclusion as extraordinary intervention with serious event audit
Use of seclusion should be considered an extraordinary and exceptional intervention. Each intervention should be subject to a serious event audit, conducted by a professional outside the service provider’s learning disabilities services. This audit should be shared with the person’s next of kin and the RQIA.
Matched on
classifier match
Inquiry recommendation
45match
R3 - Non-acceptance notification within three months
With the exception of Recommendations 88 and 89 (R88 & R89) any other organisation that does not accept a recommendation for which it is named as responsible, should write within three months of this report to the DoH Permanent Secretary to explain why it does not accept the recommendation. In respect of any recommendation not implemented or where...
Matched on
classifier match
Inquiry recommendation
45match
R2 - Public acceptance of recommendations within six months
The DoH should indicate publicly within six months of this report which recommendations it accepts and those it does not accept (and why). This should include the recommendations for all organisations for which the DoH holds primary responsibility. In relation to those recommendations that are accepted, any not implemented, or where there is a failure substantially to progress...
Matched on
classifier match
Inquiry recommendation
45match
MACP-3 - Grant Her Majesty's Inspectors full powers to inspect all Police Services.
That Her Majesty's Inspectors of Constabulary (HMIC) be granted full and unfettered powers and duties to inspect all parts of Police Services including the Metropolitan Police Service.
Matched on
classifier match
Inquiry recommendation
41match
60 - Independent school governance standards
The Department for Education and the Welsh Government should: amend the Independent School Standards to include the requirements that there is an effective system of governance, based on three principles of openness to external scrutiny, transparency and honesty within the governance arrangements, and the ability of governors to have difficult conversations both internally and with those providing external...
Matched on
classifier match
Inquiry recommendation
41match
49 - Catholic non-compliance framework
The Catholic Bishops' Conference of England and Wales and the Conference of Religious should publish a clear framework for dealing with cases of non-compliance with safeguarding policies and procedures. That framework should identify who is responsible for dealing with issues of non-compliance at all levels of the Church, and include the measures or sanctions for non-compliance.
Matched on
classifier match
Inquiry recommendation
41match
46 - Church independent external safeguarding audits
The Church in Wales should introduce independent external auditing of its safeguarding policies and procedures, as well as the effectiveness of safeguarding practice in dioceses, cathedrals and other Church organisations. Audits should be conducted regularly and reports should be published. The Church of England should continue independent external auditing of its safeguarding policies and procedures, as well as...
Matched on
classifier match
Inquiry recommendation
41match
R81 - Expert clinical governance advisory function
The DoH should establish an expert clinical/social governance advisory function to support providers.
Matched on
classifier match
Inquiry recommendation
41match
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
41match
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
classifier match
Inquiry recommendation
41match
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
classifier match
Inquiry recommendation
41match
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
classifier match
Inquiry recommendation
41match
R66 - Quarterly safeguarding file audit
A quarterly multidisciplinary audit of 10% of safeguarding files per ward or residential unit should be conducted. Findings must be integrated with incident data and reported to the Executive Team, NEDs and the Strategic Planning and Performance Group (SPPG).
Matched on
classifier match
Inquiry recommendation
41match
R64 - Safeguarding dashboard with screening decisions
The dashboard should include the number of allegations reported, together with the screening decision (referral to the Adult Safeguarding Gateway, referral to the joint protocol or no further action). Particular scrutiny should be given to allegations of abuse by staff that are screened out due to lack of supporting evidence. The DoH Northern Ireland should develop such a...
Matched on
classifier match
Inquiry recommendation
41match
R43 - Red-rated complaints shared with all NEDs
All complaints managed at corporate level and rated as red (using the red, amber and green (RAG) rating matrix) should be shared with all non-executive directors (NEDs) on the Board.
Matched on
classifier match
Inquiry recommendation
41match
R30 - NED champion for restraint reduction
HSCTs should appoint a non-executive director (NED) to act as a champion for restraint reduction, with a mandate to hold executive directors accountable for delivery.
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classifier match
Inquiry recommendation
41match
R27 - RQIA assurance of property processes
RQIA should examine the provider organisation’s internal assurance processes and make recommendations where they are insufficient.
Matched on
classifier match
Inquiry recommendation
41match
R23 - Regular property and finance compliance checks
All organisations taking responsibility for property and/or finance for people with learning disabilities and autistic people should institute regular checks of adherence to their policies. This includes local checks, corporate checks and periodic internal audit checks.
Matched on
classifier match
Inquiry recommendation
41match
R14 - Restraint and seclusion observation records
Observation records detailing all use of restraint and seclusion should be completed by the individual observing. In HSCT facilities, if the observer is unregistered, a registered staff member should countersign the entry rather than create a second-hand record. In private and 3rd sector facilities the individual in charge of the shift must countersign and report to the Registered...
Matched on
classifier match
Inquiry recommendation
41match
BRIS-73 - Grant Council powers to enforce good regulation principles and consistent professional body behaviour
The Council for the Regulation of Healthcare Professionals should have formal powers to require bodies which regulate the separate groups of healthcare professionals to conform to principles of good regulation. It should act as a source of guidance and of good practice. It should seek to ensure that in practice the bodies which regulate healthcare professionals behave in...
Matched on
classifier match
Inquiry recommendation
41match
BRIS-72 - Prioritise establishing statutory Council for Regulation of Healthcare Professionals with broad membership
The Council for the Regulation of Healthcare Professionals should be established as a matter of priority. It should have a statutory basis. It should report to Parliament. It should have a broadly-based membership, consisting of representatives of the bodies which regulate the various groups of healthcare professionals, of the NHS, and of the general public.
Matched on
classifier match
Inquiry recommendation
41match
BRIS-71 - Establish a single body to coordinate all healthcare professional regulatory bodies
In addition, a single body should be charged with the overall co-ordination of the various professional bodies and with integrating the various systems of regulation. It should be called the Council for the Regulation of Healthcare Professionals. (In effect, this is the body currently proposed in ‘The NHS Plan’, and referred to as the Council of Healthcare Regulators.)...
Matched on
classifier match
Inquiry recommendation
41match
BRIS-70 - Establish single regulatory bodies for each distinct healthcare professional group
For each group of healthcare professionals (doctors, nurses and midwives, the professions allied to medicine, and managers) there should be one body charged with overseeing all aspects relating to the regulation of professional life: education, registration, training, CPD, revalidation and discipline. The bodies should be: for doctors, the GMC; for nurses and midwives, the new Nursing and Midwifery...
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classifier match