Contents
Introduction 4
Accountability for implementation of the recommendations 7
IMPLEMENTING THE RECOMMENDATIONS 7
Recommendation 1 7
Recommendation 2 9
Shared core values and standards 9
Leadership at all levels 9
Information on the attainment of the values and standards 9
Measuring cultural health 10
Putting the patient first 11
CLARITY OF VALUES AND PRINCIPLES 11
Recommendation 3 11
Recommendation 4 12
Recommendation 5 12
Recommendation 6 14
Recommendation 7 14
Recommendation 8 15
Fundamental standards of behaviour 16
Recommendation 9 16
Recommendation 10 17
Recommendation 11 17
Recommendation 12 18
A common culture made real throughout the system - an integrated hierarchy of standards of service 20
THE NATURE OF STANDARDS 20
Recommendation 13 20
Recommendation 14 22
Recommendation 15 23
RESPONSIBILITY FOR SETTING STANDARDS 24
Recommendation 16 24
Recommendation 17 25
Recommendation 18 26
Responsibility for, and effectiveness of, healthcare standards 28
GAPS BETWEEN THE UNDERSTOOD FUNCTIONS OF SEPARATE REGULATORS 29
Recommendation 19 29
RESPONSIBILITY FOR REGULATING AND MONITORING COMPLIANCE 30
Recommendation 20 30
Recommendation 21 30
Recommendation 22 31
Recommendation 23 32
Recommendation 24 33
Recommendation 25 34
Recommendation 26 35
Recommendation 27 35
SANCTIONS AND INTERVENTIONS FOR NON-COMPLIANCE 36
Recommendation 28 36
Recommendation 29 38
INTERIM MEASURES 39
Recommendation 30 39
Recommendation 31 39
Recommendation 32 41
Recommendation 33 41
Recommendation 34 42
NEED TO SHARE INFORMATION BETWEEN REGULATORS 43
Recommendation 35 43
USE OF INFORMATION FOR EFFECTIVE REGULATION 44
Recommendation 36 44
USE OF INFORMATION ABOUT COMPLIANCE BY REGULATOR FROM QUALITY ACCOUNTS 45
Recommendation 37 45
USE OF INFORMATION ABOUT COMPLIANCE BY REGULATOR FROM COMPLAINTS 46
Recommendation 38 46
Recommendation 39 47
Recommendation 40 48
USE OF INFORMATION ABOUT COMPLIANCE BY REGULATOR FROM PATIENT SAFETY ALERTS 49
Recommendation 41 49
USE OF INFORMATION ABOUT COMPLIANCE BY REGULATOR FROM SERIOUS UNTOWARD INCIDENTS 49
Recommendation 42 49
USE OF INFORMATION ABOUT COMPLIANCE BY REGULATOR FROM MEDIA 50
Recommendation 43 50
Recommendation 44 51
USE OF INFORMATION ABOUT COMPLIANCE BY REGULATOR FROM INQUESTS 52
Recommendation 45 52
USE OF INFORMATION ABOUT COMPLIANCE BY REGULATOR FROM QUALITY AND RISK PROFILES 53
Recommendation 46 53
USE OF INFORMATION ABOUT COMPLIANCE BY REGULATOR FROM FOUNDATION TRUST GOVERNORS, SCRUTINY COMMITTEES 53
Recommendation 47 53
Recommendation 48 54
ENHANCEMENT OF MONITORING AND THE IMPORTANCE OF INSPECTION 55
Recommendation 49 55
Recommendation 50 56
Recommendation 51 56
Recommendation 52 57
CARE QUALITY COMMISSION INDEPENDENCE, STRATEGY AND CULTURE 58
Recommendation 53 58
Recommendation 54 59
Recommendation 55 59
Recommendation 56 60
Recommendation 57 60
Recommendation 58 61
Recommendation 59 62
Responsibility for, and effectiveness of, regulating healthcare systems governance - Monitor's healthcare systems regulatory functions 63
CONSOLIDATION OF REGULATORY FUNCTIONS 63
Recommendation 60 63
Recommendation 61 64
IMPROVED PATIENT FOCUS 65
Recommendation 62 65
IMPROVED TRANSPARENCY 66
Recommendation 63 66
AUTHORISATION OF FOUNDATION TRUSTS 66
Recommendation 64 66
QUALITY OF CARE AS A PRE-CONDITION FOR FOUNDATION TRUST APPLICATIONS 67
Recommendation 65 67
IMPROVING CONTRIBUTION OF STAKEHOLDER OPTIONS 68
Recommendation 66 68
FOCUS ON COMPLIANCE WITH FUNDAMENTAL STANDARDS 68
Recommendation 67 68
Recommendation 68 69
Recommendation 69 69
DUTY OF UTMOST GOOD FAITH 70
Recommendation 70 70
ROLE OF SECRETARY OF STATE 71
Recommendation 71 71
ASSESSMENT PROCESS FOR AUTHORISATION 71
Recommendation 72 71
NEED FOR CONSTRUCTIVE WORKING WITH OTHER PARTS OF THE SYSTEM 72
Recommendation 73 72
ENHANCEMENT OF ROLE OF GOVERNORS 72
Recommendation 74 72
Recommendation 75 73
Recommendation 76 74
Recommendation 77 74
Recommendation 78 75
ACCOUNTABILITY OF PROVIDERS' DIRECTORS 75
Recommendation 79 75
Recommendation 80 76
Recommendation 81 77
Recommendation 82 78
Recommendation 83 78
Recommendation 84 79
Recommendation 85 79
REQUIREMENT OF TRAINING OF DIRECTORS 80
Recommendation 86 80
Responsibility for, and effectiveness of, regulating healthcare systems governance - Health and Safety Executive functions in healthcare settings 82
ENSURING THE UTILITY OF A HEALTH AND SAFETY FUNCTION IN A CLINICAL SETTING 82
Recommendation 87 82
INFORMATION SHARING 83
Recommendation 88 83
Recommendation 89 84
ASSISTANCE IN DECIDING ON PROSECUTIONS 84
Recommendation 90 84
Enhancement of the role of supportive agencies 85
NHS LITIGATION AUTHORITY IMPROVEMENT OF RISK MANAGEMENT 85
Recommendation 91 85
Recommendation 92 86
Recommendation 93 87
EVIDENCE-BASED ASSESSMENT 87
Recommendation 94 87
INFORMATION SHARING 88
Recommendation 95 88
Recommendation 96 88
NATIONAL PATIENT SAFETY AGENCY FUNCTIONS 89
Recommendation 97 89
Recommendation 98 90
Recommendation 99 90
Recommendation 100 91
Recommendation 101 92
TRANSPARENCY, USE AND SHARING OF INFORMATION 93
Recommendation 102 93
Recommendation 103 94
Recommendation 104 94
Recommendation 105 95
HEALTH PROTECTION AGENCY COORDINATION AND PUBLICATION OF PROVIDERS' INFORMATION ON HEALTHCARE ASSOCIATED INFECTIONS 96
Recommendation 106 96
SHARING CONCERNS 96
Recommendation 107 96
SUPPORT FOR OTHER AGENCIES 97
Recommendation 108 97
Effective complaints handling 98
Recommendation 109 98
LOWERING BARRIERS 100
Recommendation 110 100
Recommendation 111 100
Recommendation 112 101
COMPLAINTS HANDLING 102
Recommendation 113 102
Recommendation 114 103
INVESTIGATIONS 104
Recommendation 115 104
SUPPORT FOR COMPLAINTS 105
Recommendation 116 105
Recommendation 117 107
LEARNING AND INFORMATION FROM COMPLAINTS 107
Recommendation 118 107
Recommendation 119 108
Recommendation 120 109
Recommendation 121 110
HANDLING LARGE-SCALE COMPLAINTS 111
Recommendation 122 111
Commissioning for standards 113
RESPONSIBILITY FOR MONITORING DELIVERY OF STANDARDS AND QUALITY 113
Recommendation 123 113
DUTY TO REQUIRE AND MONITOR DELIVERY OF FUNDAMENTAL STANDARDS 115
Recommendation 124 115
RESPONSIBILITY FOR REQUIRING AND MONITORING DELIVERY OF ENHANCED STANDARDS 116
Recommendation 125 116
PRESERVING CORPORATE MEMORY 116
Recommendation 126 116
RESOURCES FOR SCRUTINY 118
Recommendation 127 118
EXPERT SUPPORT 119
Recommendation 128 119
ENSURING ASSESSMENT AND ENFORCEMENT OF FUNDAMENTAL STANDARDS THROUGH CONTRACTS 120
Recommendation 129 120
RELATIVE POSITION OF COMMISSIONER AND PROVIDER 120
Recommendation 130 120
DEVELOPMENT OF ALTERNATIVE SOURCES OF PROVISION 121
Recommendation 131 121
MONITORING TOOLS 121
Recommendation 132 121
ROLE OF COMMISSIONERS IN PROVISION OF SUPPORT FOR COMPLAINTS 122
Recommendation 133 122
ROLE OF COMMISSIONERS IN PROVISION OF SUPPORT FOR COMPLAINANTS 124
Recommendation 134 124
PUBLIC ACCOUNTABILITY OF COMMISSIONERS AND PUBLIC ENGAGEMENT 124
Recommendation 135 124
Recommendation 136 126
INTERVENTION AND SANCTIONS FOR SUBSTANDARD OR UNSAFE SERVICES 127
Recommendation 137 127
Local scrutiny 129
Recommendation 138 129
Performance management and strategic oversight 130
THE NEED TO PUT PATIENTS FIRST AT ALL TIMES 130
Recommendation 139 130
PERFORMANCE MANAGERS WORKING CONSTRUCTIVELY WITH REGULATORS 131
Recommendation 140 131
TAKING RESPONSIBILITY FOR QUALITY 131
Recommendation 141 131
CLEAR LINES OF RESPONSIBILITY SUPPORTED BY GOOD INFORMATION FLOW 132
Recommendation 142 132
CLEAR METRICS ON QUALITY 133
Recommendation 143 133
NEED FOR OWNERSHIP OF QUALITY METRICS AT A STRATEGIC LEVEL 134
Recommendation 144 134
Patient, public and local scrutiny 135
STRUCTURE OF LOCAL HEALTHWATCH 135
Recommendation 145 135
FINANCE AND OVERSIGHT OF LOCAL HEALTHWATCH 136
Recommendation 146 136
COORDINATION OF LOCAL PUBLIC SCRUTINY BODIES 137
Recommendation 147 137
TRAINING 138
Recommendation 148 138
EXPERT ASSISTANCE 138
Recommendation 149 138
INSPECTION POWERS 139
Recommendation 150 139
COMPLAINTS TO MPS 139
Recommendation 151 139
Medical training and education 141
MEDICAL TRAINING 141
Recommendation 152 141
Recommendation 153 142
Recommendation 154 142
Recommendation 155 143
Recommendation 156 144
MATTERS TO BE REPORTED TO THE GENERAL MEDICAL COUNCIL 144
Recommendation 157 144
TRAINING AND TRAINING ESTABLISHMENTS AS A SOURCE OF SAFETY INFORMATION 145
Recommendation 158 145
Recommendation 159 145
Recommendation 160 145
Recommendation 161 146
Recommendation 162 146
SAFE STAFF NUMBERS AND SKILLS 147
Recommendation 163 147
APPROVED PRACTICE SETTINGS 147
Recommendation 164 147
Recommendation 165 148
Recommendation 166 148
Recommendation 167 149
Recommendation 168 149
ROLE OF THE DEPARTMENT OF HEALTH AND THE NATIONAL QUALITY BOARD 150
Recommendation 169 150
HEALTH EDUCATION ENGLAND 151
Recommendation 170 151
DEANS 152
Recommendation 171 152
PROFICIENCY IN THE ENGLISH LANGUAGE 152
Recommendation 172 152
Openness, transparency and candour 154
PRINCIPLES OF OPENNESS, TRANSPARENCY AND CANDOUR 154
Recommendation 173 154
CANDOUR ABOUT HARM 155
Recommendation 174 155
Recommendation 175 156
OPENNESS WITH REGULATORS 156
Recommendation 176 156
OPENNESS IN PUBLIC STATEMENTS 157
Recommendation 177 157
IMPLEMENTATION OF THE DUTY: ENSURING CONSISTENCY OF OBLIGATIONS UNDER THE DUTY OF OPENNESS, TRANSPARENCY AND CANDOUR 157
Recommendation 178 157
IMPLEMENTATION OF THE DUTY: RESTRICTIVE CONTRACTUAL CLAUSES 158
Recommendation 179 158
IMPLEMENTATION OF THE DUTY: CANDOUR ABOUT INCIDENTS 159
Recommendation 180 159
ENFORCEMENT OF THE DUTY: STATUTORY DUTIES OF CANDOUR IN RELATION TO HARM TO PATIENTS 159
Recommendation 181 159
ENFORCEMENT OF THE DUTY: STATUTORY DUTY OF OPENNESS AND TRANSPARENCY 160
Recommendation 182 160
ENFORCEMENT OF THE DUTY: CRIMINAL LIABILITY 161
Recommendation 183 161
ENFORCEMENT BY THE CARE QUALITY COMMISSION 162
Recommendation 184 162
Nursing 163
FOCUS ON CULTURE OF CARING 163
Recommendation 185 163
PRACTICAL HANDS-ON TRAINING AND EXPERIENCE 165
Recommendation 186 165
Recommendation 187 166
APTITUDE TEST FOR COMPASSION AND CARING 167
Recommendation 188 167
CONSISTENT TRAINING 168
Recommendation 189 168
NATIONAL STANDARDS 169
Recommendation 190 169
RECRUITMENT FOR VALUES AND COMMITMENT 169
Recommendation 191 169
STRONG NURSING VALUES 171
Recommendation 192 171
STANDARDS FOR APPRAISAL AND SUPPORT 171
Recommendation 193 171
Recommendation 194 172
NURSE LEADERSHIP 173
Recommendation 195 173
Recommendation 196 174
Recommendation 197 175
MEASURING CULTURAL HEALTH 176
Recommendation 198 176
KEY NURSES 177
Recommendation 199 177
Recommendation 200 177
STRENGTHENING THE NURSING PROFESSIONAL VOICE 179
Recommendation 201 179
Recommendation 202 179
Recommendation 203 179
Recommendation 204 180
Recommendation 205 180
Recommendation 206 181
STRENGTHENING IDENTIFICATION OF HEALTHCARE SUPPORT WORKERS AND NURSES 181
Recommendation 207 181
Recommendation 208 182
REGISTRATION OF HEALTHCARE SUPPORT WORKERS 182
Recommendation 209 182
CODE OF CONDUCT FOR HEALTHCARE SUPPORT WORKERS 183
Recommendation 210 183
TRAINING STANDARDS FOR HEALTHCARE SUPPORT WORKERS 184
Recommendation 211 184
Recommendation 212 184
Recommendation 213 184
Leadership 186
SHARED TRAINING 186
Recommendation 214 186
SHARED CODE OF ETHICS 187
Recommendation 215 187
LEADERSHIP FRAMEWORK 187
Recommendation 216 187
COMMON SELECTION CRITERIA 188
Recommendation 217 188
ENFORCEMENT OF STANDARDS AND ACCOUNTABILITY 189
Recommendation 218 189
A REGULATOR AS AN ALTERNATIVE 190
Recommendation 219 190
ACCREDITATION 190
Recommendation 220 190
ENSURING COMMON STANDARDS OF COMPETENCE AND COMPLIANCE 191
Recommendation 221 191
Professional regulation of fitness to practise 192
GENERAL MEDICAL COUNCIL: SYSTEMIC INVESTIGATION WHERE NEEDED 192
Recommendation 222 192
GENERAL MEDICAL COUNCIL: ENHANCED RESOURCES 193
Recommendation 223 193
GENERAL MEDICAL COUNCIL: INFORMATION SHARING 193
Recommendation 224 193
GENERAL MEDICAL COUNCIL: PEER REVIEWS 194
Recommendation 225 194
NURSING AND MIDWIFERY COUNCIL: INVESTIGATION OF SYSTEMIC CONCERNS 194
Recommendation 226 194
Recommendation 227 194
NURSING AND MIDWIFERY COUNCIL: ADMINISTRATIVE REFORM 195
Recommendation 228 195
NURSING AND MIDWIFERY COUNCIL: REVALIDATION 196
Recommendation 229 196
NURSING AND MIDWIFERY COUNCIL: PROFILE 196
Recommendation 230 196
NURSING AND MIDWIFERY COUNCIL: COORDINATION WITH INTERNAL PROCEDURES 197
Recommendation 231 197
NURSING AND MIDWIFERY COUNCIL: EMPLOYMENT LIAISON OFFICERS 197
Recommendation 232 197
FOR JOINT ACTION: PROFILE 198
Recommendation 233 198
FOR JOINT ACTION: COOPERATION WITH THE CARE QUALITY COMMISSION 198
Recommendation 234 198
FOR JOINT ACTION: JOINT PROCEEDINGS 199
Recommendation 235 199
Caring for the elderly (applicable to all patients but requiring special attention for the elderly) 200
IDENTIFICATION OF WHO IS RESPONSIBLE FOR THE PATIENT 201
Recommendation 236 201
TEAMWORK 201
Recommendation 237 201
COMMUNICATION WITH AND ABOUT PATIENTS 202
Recommendation 238 202
CONTINUING RESPONSIBILITY FOR CARE 205
Recommendation 239 205
HYGIENE 206
Recommendation 240 206
PROVISION OF FOOD AND DRINK 207
Recommendation 241 207
MEDICINES ADMINISTRATION 208
Recommendation 242 208
RECORDING OF ROUTINE OBSERVATIONS 210
Recommendation 243 210
Information 212
COMMON INFORMATION PRACTICES, SHARED DATA AND ELECTRONIC RECORDS 212
Recommendation 244 212
BOARD ACCOUNTABILITY 214
Recommendation 245 214
COMPARABLE QUALITY ACCOUNTS 215
Recommendation 246 215
ACCOUNTABILITY FOR QUALITY ACCOUNTS 216
Recommendation 247 216
Recommendation 248 216
Recommendation 249 218
Recommendation 250 219
REGULATORY OVERSIGHT OF QUALITY ACCOUNTS 220
Recommendation 251 220
ACCESS TO DATA 220
Recommendation 252 220
ACCESS TO QUALITY AND RISK PROFILE 222
Recommendation 253 222
ACCESS FOR PUBLIC AND PATIENTS COMMENTS 223
Recommendation 254 223
USING PATIENTS FEEDBACK 223
Recommendation 255 223
FOLLOWING UP PATIENTS 224
Recommendation 256 224
ROLE OF THE HEALTH AND SOCIAL CARE INFORMATION CENTRE 226
Recommendation 257 226
Recommendation 258 227
Recommendation 259 227
INFORMATION STANDARDS 228
Recommendation 260 228
Recommendation 261 229
ENHANCING THE USE, ANALYSIS AND DISSEMINATION OF HEALTHCARE INFORMATION 229
Recommendation 262 229
Recommendation 263 230
Recommendation 264 231
Recommendation 265 232
Recommendation 266 232
Recommendation 267 232
RESOURCES 233
Recommendation 268 233
IMPROVING AND ASSURING ACCURACY 233
Recommendation 269 233
Recommendation 270 235
Recommendation 271 235
Recommendation 272 236
Coroners and inquests 237
INFORMATION TO CORONERS 237
Recommendation 273 237
Recommendation 274 238
INDEPENDENT MEDICAL EXAMINERS 238
Recommendation 275 238
Recommendation 276 239
DEATH CERTIFICATION 239
Recommendation 277 239
Recommendation 278 239
Recommendation 279 240
APPROPRIATE AND SENSITIVE CONTACT WITH BEREAVED FAMILIES 241
Recommendation 280 241
Recommendation 281 241
INFORMATION FOR, AND FROM, INQUESTS 242
Recommendation 282 242
Recommendation 283 242
APPOINTMENT OF ASSISTANT DEPUTY CORONERS 242
Recommendation 284 242
APPOINTMENT OF ASSISTANT DEPUTY CORONERS 243
Recommendation 285 243
Department of Health leadership 244
IMPACT ASSESSMENTS BEFORE STRUCTURAL CHANGE 244
Recommendation 286 244
Recommendation 287 245
CLINICAL INPUT 246
Recommendation 288 246
EXPERIENCE ON THE FRONT LINE 246
Recommendation 289 246
Recommendation 290 246