Contents
Foreword by the Secretary of State for Health 5
Statement of Common Purpose 7
Executive Summary 10
PREVENTING PROBLEMS 12
Culture 12
Openness and candour 13
Listening to patients 14
Safe staffing 15
DETECTING PROBLEMS QUICKLY 16
TAKING ACTION PROMPTLY 18
ENSURING ROBUST ACCOUNTABILITY 19
ENSURING STAFF ARE TRAINED AND MOTIVATED 21
CONCLUSION 22
Introduction: Changing culture 23
Chapter 1. Preventing problems 26
SUMMARY 26
A culture of high quality care 28
People as partners - a conversation of equals 28
A common language - the NHS Constitution 29
Compassionate care 34
The power of information 36
The responsibilities of patients and the public 37
A strong voice for patients - Healthwatch 38
Listening to complaints, and acting on them 39
Safe care for patients 42
A learning and improvement culture 43
Patient safety culture 44
Transparency and measurement 46
Openness and candour 47
Safe care for each and every patient: the role of the named clinician 48
Supporting staff to care 50
Staff wellbeing and improved care outcomes 50
Values based recruitment 51
Ensuring safe staffing 52
CONCLUSION 56
Chapter 2. Detecting problems quickly 57
SUMMARY 57
Effective inspection 58
Inspecting hospitals and listening to patients 58
Standards with consequences 60
Fundamental standards 60
Enhanced and developmental standards 62
Speaking out safely 63
Clear, strong governance: the role of boards 63
Scrutiny and asking good questions 64
Commissioning for quality 65
Working together 65
Chapter 3. Taking action promptly 68
SUMMARY 68
Clear, meaningful ratings 69
Clear, risk-based intervention 70
Warning notices and enforcement action 71
Special measures 71
Service redesign and administration 72
CONCLUSION 72
Chapter 4. Ensuring robust accountability 73
SUMMARY 73
The responsibilities of Boards and leaders 74
Ensuring quality and safety: the role of Boards 76
Developing the board's own capability 77
Fit and proper persons 77
False or misleading information 78
Breaches of fundamental standards 79
The role of professional regulation 79
Commissioning for quality, safety and compassionate care 80
The role of Government 83
Coroners and medical examiners 86
Chapter 5. Ensuring staff are trained and motivated 88
SUMMARY 88
Staff engagement 89
Education and training 92
Nursing and compassionate care 93
Safe, compassionate care for older people 94
Nurse leadership 96
Revalidation 96
Direct experience of care 97
Healthcare assistants and support workers in the NHS and social care settings 97
Recruitment, training and education 99
Making caring a career 99
Effective leadership 99
Time to care 100
Disclosure and barring service 101
Reducing burdens 102
Improving leadership 102
Attracting top talent to senior leadership roles - a new NHS executive fast-track programme 103
Developing leaders already in the NHS and investing in a talent pipeline for the future 104
Integrated and system leadership 104
Chapter 6. Conclusion: Learning from Mid Staffordshire 106
Annex A. Review into Healthcare Assistants and Support Workers in the NHS and Social Care Settings 107
REVIEW FINDINGS 107
WHAT THE REVIEW RECOMMENDED 108
RESPONDING TO THE REVIEW AND NEXT STEPS 108
RECRUITMENT, TRAINING AND EDUCATION 108
MAKING CARING A CAREER 109
EFFECTIVE LEADERSHIP, SUPERVISION AND SUPPORT FOR HEALTH AND SOCIAL CARE SUPPORT WORKERS 109
TIME TO CARE 110
Annex B. Review into the quality and safety of care at 14 NHS hospital Trusts in England 112
REVIEW FINDINGS 112
WHAT THE REVIEW RECOMMENDED 113
RESPONDING TO THE REVIEW AND NEXT STEPS 113
KEY ACTIONS 114
Annex C. Improving the safety of patients in England 116
REVIEW FINDINGS 116
WHAT THE REVIEW RECOMMENDED 116
RESPONDING TO THE REVIEW AND NEXT STEPS 117
Annex D. A Review of the NHS Hospitals Complaints System: Putting Patients Back in the Picture 119
BACKGROUND 119
REVIEW FINDINGS 119
WHAT THE REVIEW RECOMMENDED 120
RESPONDING TO THE REVIEW AND NEXT STEPS 120
LOCAL ACTION 120
LOCAL ACTION - THROUGH THE LOCAL HEALTHWATCH NETWORK 122
NATIONAL ACTION 122
THE OMBUDSMAN 123
Annex E. Burdens review 124
BACKGROUND 124
REVIEW FINDINGS 124
WHAT THE REVIEW RECOMMENDED 124
RESPONDING TO THE REVIEW AND NEXT STEPS 125
Annex F. Children and Young People's Health Outcomes Forum's report for the Secretary of State for Health 126
BACKGROUND 126
REVIEW FINDINGS 126
WHAT THE REVIEW RECOMMENDED 127
RESPONDING TO THE REVIEW AND NEXT STEPS 127
Annex G. The NHS - Key Players 128
Endnotes 130