Quality and safety oversight
Failure to adequately assess, monitor, evaluate, and improve the quality and safety of services, hindering continuous improvement.
1,292 items
15 sources
18 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
CQC action
93match
Cedar House
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
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
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
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
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
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
Inquiry recommendation
82match
LADB-20 - Strengthen safety audit processes and improve communication quality during audits
The safety audit process should be strengthened, and the quality of communication during the process should be improved (para 9.44).
Matched on
terms: quality, safety
Inquiry recommendation
82match
BRIS-160 - Focus public involvement on NHS service development, delivery, safety, and quality regulation
The public’s involvement in the NHS should particularly be focused on the development and planning of healthcare services and on the operation and delivery of healthcare services, including the regulation of safety and quality, the competence of healthcare professionals, and the protection of vulnerable groups.
Matched on
terms: quality, safety
CQC action
81match
Cygnet Bury Hudson
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
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
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
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
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
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
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
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
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
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
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.
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
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
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
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
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
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
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
70match
MAI-126 - Assess quality of first responder training
The Home Office and the College of Policing should regularly assess and appraise the training on first responder interventions provided by each police service to ensure that it is of an appropriate quality and that adequate time is allocated to it.
Matched on
terms: quality
Committee recommendation
70match
#31 - Seriously improve the Energy Company Obligation policy to clarify installer accountability for poor quality retrofit work.
We found it incredible that the Residential Property Surveyors Association has reported that around 250,000 homes could be un-mortgageable due to spray foam insulation and that the accountability to remedy things remains unclear. We recommend that the Energy Company Obligation, as a policy to put responsibility on installers and commissioners for poor quality work, needs serious improvement. (Recommendation,...
Matched on
terms: quality
Inquiry recommendation
69match
F72 - Assessment process for authorisation
The assessment for an authorisation of applicant for foundation trust status should include a full physical inspection of its primary clinical areas as well as all wards to determine whether it is compliant with fundamental safety and quality standards.
Matched on
terms: quality, safety
Inquiry recommendation
69match
F69 - Focus on compliance with fundamental standards
The assessment criteria for authorisation should include a requirement that applicants demonstrate their ability to consistently meet fundamental patient safety and quality standards at the same time as complying with the financial and corporate governance requirements of a foundation trust.
Matched on
terms: quality, safety
CQC action
69match
Chatham House
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
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
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
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
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
Committee recommendation
66match
#8 - Improve regulator oversight of debt levels and simplify water company financial structures
The Independent Water Commission should determine how regulators can have better oversight over debt levels in regulated entities and other connected companies. Its proposals should actively require companies to simplify structures to allow for greater regulation and oversight of any company’s true financial situation. (Recommendation, Paragraph 21)
Matched on
terms: oversight
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
F19 - Gaps between the understood functions of separate regulators
There should be a single regulator dealing both with corporate governance, financial competence, viability and compliance with patient safety and quality standards for all trusts.
Matched on
terms: quality, safety
CQC action
65match
Brook House Residential Home
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
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
There were not effective systems in place to assess and monitor the quality of the service provided.
Matched on
terms: quality
Inquiry recommendation
62match
HIDD-38 - Urgently use outside consultants to review safety management and communication issues
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
Inquiry recommendation
62match
MAI-62 - LRF oversight of lessons from exercises and incidents
Local resilience forums should establish procedures to ensure that they oversee the process of identifying the lessons to be learned from major exercises, or serious incidents, in their areas, and that they are responsible for overseeing the debriefing of those events.
Matched on
terms: oversight
Committee recommendation
62match
#4 - Mandate greater Ofwat oversight and clearer criteria for water company senior bonuses
The Independent Water Commission should consider what other reforms are necessary to ensure that the right people are put into senior positions and the appropriate bonuses are paid to them. This should include greater oversight or approval from Ofwat before appointments are made and bonuses are paid; clearer statutory expectations on the criteria for bonuses, making sure that...
Matched on
terms: oversight
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
Committee recommendation
61match
#8 - Routine rail assistance failures are unacceptable and must become vanishingly rare occurrences.
The seemingly routine, everyday nature of assistance failures on the rail network is unacceptable. Accessibility must not be viewed through the same lens as customer service, where less than 100 per cent performance is considered normal. Accessibility failures should be vanishingly rare, not commonplace, but too few actors in the system currently behave as if that is the...
Matched on
terms: safety
Committee recommendation
61match
#20 - Reform regulatory frameworks to ensure effective environmental protection is a priority for companies.
The Independent Water Commission should look at potential reforms of the regulatory frameworks and regulators that govern the water sector to ensure that environmental protection is effective and a priority for water companies. It is vital that the reforms the Commission proposes can accommodate and synchronise with wider reforms, such as those that aim to tackle all water...
Matched on
terms: quality
CQC action
61match
Serenity House
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
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