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
Source spread
Where this theme appears
Quality and safety oversight has been flagged across 1 independent accountability source:
440 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (440) — showing 50 strongest matches
64 — Welsh independent school standards update
Recommendation: 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 …
Gov response: On 30 June 2022, the Welsh Government stated that it will amend and strengthen the independent school regulations, and that work is ongoing to draft the legislation. The Welsh Government also stated that it will …
Accepted
60 — Independent school governance standards
Recommendation: 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 …
Gov response: On 30 June 2022, the UK government stated that it agreed with the first two points of the recommendation in principle. It stated that it intended to consult on revised Independent School Standards in 2023 …
Accepted in Part
No update 2+ yrs
58 — Residential schools inspection and guardians registration
Recommendation: 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 …
Gov response: On 30 June 2022, the UK government stated that it was still of the view that the best way to protect children in residential special schools was to strengthen the National Minimum Standards (NMS), and …
Accepted in Part
No update 2+ yrs
50 — Independent validation of Catholic audit programme
Recommendation: 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.
Gov response: On 30 September 2021, the Catholic Council for the Inquiry stated that the Catholic Safeguarding Standards Agency (CSSA) Board is committed to the independent verification of its audit processes, and would undertake a formal process …
Accepted
No update 2+ yrs
49 — Catholic non-compliance framework
Recommendation: 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 …
Gov response: On 30 September 2021, the Catholic Council for the Inquiry stated that the trustee bodies of all Catholic dioceses and religious orders were invited to subscribe to the Catholic Safeguarding Standards Agency. The Catholic Safeguarding …
Accepted
No update 2+ yrs
47 — Catholic lead clergy for safeguarding
Recommendation: 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 …
Gov response: On 30 April 2021, the Catholic Council for the Inquiry stated that the role description for the Lead Bishop for the Catholic Bishops' Conference of England and Wales was approved and Bishop Paul Mason was …
Accepted
46 — Church independent external safeguarding audits
Recommendation: 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. …
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that it remained committed to their programme of five-yearly independent audits. The joint …
Accepted
No update 2+ yrs
FR-2 — Child Protection Authorities
Recommendation: 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 …
Gov response: We accept the need for a stronger safeguarding system. We will ensure the relevant actions included within our reform programme, Stable Homes, Built on Love, fulfil this recommendation.
Accepted in Part
In progress
7 — Catholic complaints policy with escalation process
Recommendation: 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 …
Gov response: On 30 April 2021, the Catholic Council for the Inquiry stated that a framework and template for complaints was ratified by the Bishops. The framework and template include the need for clear communication between the …
Accepted
AFA-7B — Cancer Services
Recommendation: 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 …
Response Pending
AFA-7A — Urology Service
Recommendation: 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 …
Response Pending
AFA-6 — Medical leadership and doctors in difficulty
Recommendation: 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 …
Response Pending
AFA-3 — Board and senior leadership development
Recommendation: 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 …
Response Pending
R103 — Public learning disability performance dashboard within 12 months
Recommendation: 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.
Response Pending
R84 — Learning disability service culture measure
Recommendation: 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.
Response Pending
R83 — RQIA use of CCTV in inspections
Recommendation: 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.
Response Pending
R82 — Risk-based inspection prediction
Recommendation: 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 …
Response Pending
R81 — Expert clinical governance advisory function
Recommendation: The DoH should establish an expert clinical/social governance advisory function to support providers.
Response Pending
R79 — Board member learning framework
Recommendation: 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 …
Response Pending
R78 — Audit committee implementation tracking
Recommendation: 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 …
Response Pending
R77 — Triennial Board governance reviews
Recommendation: The DoH Permanent Secretary should commission triennial reviews of each Board’s collective performance in clinical and social care governance.
Response Pending
R76 — NED with clinical governance expertise
Recommendation: 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 …
Response Pending
R75 — Executive Director of Clinical and Social Care Governance
Recommendation: 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 …
Response Pending
R67 — Independent review of systemic abuse conditions
Recommendation: 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 …
Response Pending
R66 — Quarterly safeguarding file audit
Recommendation: 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).
Response Pending
R64 — Safeguarding dashboard with screening decisions
Recommendation: 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 …
Response Pending
R62 — Monthly safeguarding dashboard
Recommendation: 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.
Response Pending
R48 — Holistic safeguarding governance review
Recommendation: 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.
Response Pending
R45 — Incident trend analysis on board dashboards
Recommendation: 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 …
Response Pending
R44 — Proactive quality assurance beyond complaints
Recommendation: 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 …
Response Pending
R43 — Red-rated complaints shared with all NEDs
Recommendation: 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.
Response Pending
R36 — Seclusion as extraordinary intervention with serious event audit
Recommendation: 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 …
Response Pending
R33 — Statistical process control charts
Recommendation: 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 …
Response Pending
R32 — Balanced performance measures including restrictive practices
Recommendation: 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, …
Response Pending
R30 — NED champion for restraint reduction
Recommendation: 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.
Response Pending
R28 — Restraint Reduction Network principles
Recommendation: 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 …
Response Pending
R27 — RQIA assurance of property processes
Recommendation: RQIA should examine the provider organisation’s internal assurance processes and make recommendations where they are insufficient.
Response Pending
R23 — Regular property and finance compliance checks
Recommendation: 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.
Response Pending
R15 — Independent care plan reviews
Recommendation: 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 …
Response Pending
R14 — Restraint and seclusion observation records
Recommendation: 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 …
Response Pending
R3 — Non-acceptance notification within three months
Recommendation: 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 …
Response Pending
R2 — Public acceptance of recommendations within six months
Recommendation: 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 …
Response Pending
R1 — Implementation monitoring group
Recommendation: 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 …
Response Pending
MACP-5 — Apply OFSTED-like standards to Police Service inspections for improved quality and reporting
Recommendation: 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 …
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MACP-3 — Grant Her Majesty's Inspectors full powers to inspect all Police Services.
Recommendation: 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.
Unknown
BRIS-73 — Grant Council powers to enforce good regulation principles and consistent professional body behaviour
Recommendation: 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 …
Unknown
BRIS-72 — Prioritise establishing statutory Council for Regulation of Healthcare Professionals with broad membership
Recommendation: 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 …
Unknown
BRIS-71 — Establish a single body to coordinate all healthcare professional regulatory bodies
Recommendation: 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 …
Unknown
BRIS-70 — Establish single regulatory bodies for each distinct healthcare professional group
Recommendation: 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 …
Unknown
HIDD-39 — Urgently introduce independent monitoring and auditing for all safety-related work
Recommendation: 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.
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