Recurring concern
Failure of care and safety auditing to identify deficiencies
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Request correctionFirst reported 28 May 2014•Latest report 16 Jun 2026
What this concern includes
Includes failures of audits or compliance-assurance processes specifically examining care and safety records, assessments, reviews, interventions, documentation or related operational practice where the audit fails to identify a material deficiency.
Not included
- Excludes generic weaknesses in governance, staffing, training or documentation unless the report directly ties them to failure of a care and safety audit.
- Excludes deficiencies in the underlying care or safety process when no audit or assurance failure is identified.
- Excludes audits of non-care public-safety activities, such as roads, signage or controlled-drug processes, unless they are explicitly part of the same care and safety auditing concern.
- Reports
- 69
- Individual concerns
- 76
- Date range
- 2014–2026
- Stated actions
- 85
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Lack of ACCT quality assurance between day 7 and post-closure review
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Share ACCT process concerns with regional commissioners and request monitoring through contract reviews and feedback to the Health and Justice Oversight Delivery Group.
Stated by NHS England -
Action
Conduct weekly ACCT completion checks and monthly regional ACCT summaries.
Stated by Guys Marsh Prison
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.
Stated by Department of Health and Social Care
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Position
HMPPS is responsible for overseeing the ACCT process, including establishment-level training, and is responding independently to ACCT concerns.
Stated by NHS England
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Concerns raised1
Lack of an audit system to check records
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Incorporate discharge-quality compliance into biannual record-keeping audits and address results through ward governance.
Stated by Sheffield Health Partnership University NHS Foundation Trust -
Action
Request regular clinical record-keeping audit reports and monitor progress through Directorate Leadership Teams and the Clinical Quality and Safety Group.
Stated by Sheffield Health Partnership University NHS Foundation Trust -
Action
Establish Trustwide, team-level supervision and spot-check audits within the clinical record-keeping quality-assurance programme.
Stated by Sheffield Health Partnership University NHS Foundation Trust
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Concerns raised1
Failure to audit for other lost patient referrals
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Audit referral forms received between 1 October 2021 and 30 November 2023 for missing forms.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure of home audits to identify care concerns
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Arrange monthly visits from the external compliance company to identify continuous-improvement needs and support new systems and processes.
Stated by Broadland View Care Home
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Recent audits did identify relevant issues; the inspection did not review the daily notes audit and disputed report terminology caused confusion.
Stated by Broadland View Care Home
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Concerns raised1
Failure to undertake recent audits of record-keeping
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Complete a documentation audit of randomly selected Laurel Suite patient records.
Stated by Stockport NHS Foundation Trust -
Action
Conduct monthly Laurel Suite record-keeping audits and review results quarterly through the Division of Medicine Quality Group.
Stated by Stockport NHS Foundation Trust
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Concerns raised1
Failure of safeguarding audit systems to identify and address ongoing issues
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Work with the Safeguarding Adults Review panel and respond to its recommendations.
Stated by Berkshire Healthcare NHS Foundation Trust -
Action
Appoint a Senior Safeguarding Lead to strengthen managerial oversight, audit cases and provide expert management of complex Section 42 enquiries.
Stated by Reading Borough Council -
Action
Strengthen safeguarding case auditing and worker supervision to identify and address practice issues.
Stated by Reading Borough Council
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Action
Introduce a Quality Assurance Framework with a programme of internal and external audits of safeguarding referrals and related learning feedback.
Stated by Reading Borough Council
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Concerns raised1
Failure to audit falls risk assessments for correctness
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Create an action plan covering falls assessment, enhanced supervision training and falls-risk-assessment auditing.
Stated by Birmingham Community Healthcare NHS Foundation Trust -
Action
Conduct spot-check reviews of falls-risk assessments during care rounding.
Stated by Birmingham Community Healthcare NHS Foundation Trust -
Action
Develop a quarterly falls-prevention effectiveness audit covering assessment correctness and care-plan impact.
Stated by Birmingham Community Healthcare NHS Foundation Trust
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Concerns raised1
Failure of ACCT audits to identify inadequate document completion
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Operate an accountability system for ACCT quality assurance, feeding findings back to staff and rectifying serious concerns.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure of 1:5 observation records to evidence five-minute checks
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Adopt five-minute observation recording sheets and audit completion at least weekly.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Review observation policy and practices against best-practice standards, guidance and potential digital innovations.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Develop a staff training package and competency assessment framework for therapeutic observations and engagement.
Stated by Greater Manchester Mental Health NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The current observation policy already requires signatures every five minutes, with completion audited weekly by the ward manager.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Failure of NEWS2 compliance auditing to reliably monitor adherence
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026