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
Failure of audits to identify and address compliance concerns
This report raised 8 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
Audit Perfect Day documentation fidelity using a standardized checklist and continue monitoring implementation through the discharge facilitation team.
Stated by North London NHS Foundation Trust -
Action
Monitor observation sheets daily and reconcile weekly CCTV and documentation reviews, with increased nurse-leader visibility.
Stated by North London NHS Foundation Trust
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Concerns raised2
Lack of regular auditing of residents’ records
Failure to identify missing incident documentation during care-record review
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
Developed an action plan addressing unwitnessed falls, medical attention, record keeping, auditing and staff training.
Stated by Green Range Limited
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Concerns raised1
Lack of audit of the cardiac component of abnormality scans
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of auditing and spot checks of surgical jig integrity
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.
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
Existing safeguards provide sufficient risk mitigation, so no additional actions are proposed at this time.
Stated by Stryker UK, Ireland, and Northern Europe
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Concerns raised1
Lack of auditing of handover documents
This report raised 6 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
Review handover sheets weekly and update them when residents’ care needs change, under management supervision.
Stated by Care UK
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Concerns raised1
Failure to audit risk assessments for referred patients not accepted by the team
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure of oversight and auditing to identify non-implementation of the call bell response time policy
Failure of oversight and auditing to identify non-completion of falls minimisation plans
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.5
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Action
Implement daily call-bell response reporting and management oversight, with delayed responses investigated and staff performance addressed.
Stated by Avery Healthcare Group -
Action
Introduce an internal audit framework covering call-bell response times and falls-minimisation plans, with results shared with staff.
Stated by Avery Healthcare Group -
Action
Conduct Quality Team compliance inspections to oversee audit findings and ensure actions are completed promptly.
Stated by Avery Healthcare Group
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Action
Introduce and operate a care-plan tracker with daily management checks and monthly care-record audits.
Stated by Avery Healthcare Group -
Action
Hold weekly clinical-risk meetings to analyse incidents, review risks and care plans, and assign actions with ownership and timescales.
Stated by Avery Healthcare Group
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Concerns raised1
Lack of auditing of SPOE referral for MDT consideration
This report raised 3 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 monthly whether Home Treatment Team discharges and onward referrals comply with the revised operating procedure.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised1
Failure of spot checks to identify and address falsified observation records
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.2
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Action
Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
Stated by East London NHS Foundation Trust -
Action
Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
Stated by East London NHS Foundation Trust
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Concerns raised2
Failure to audit the sufficiency of detail in discharge summaries
Failure to undertake wider audit of pre-discharge ECG interpretation in the Emergency Department and Acute Medical Unit
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
Conduct the second phase of the ECG process audit to assess the impact of revised documentation and education.
Stated by Manchester University NHS Foundation Trust
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
A random audit of selected ECGs is considered unable to provide assurance about interpretation quality.
Stated by Manchester University NHS Foundation Trust
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Position
Auditing all Emergency Department ECGs is considered excessively onerous and likely to distract from patient care.
Stated by Manchester University NHS Foundation Trust
Data last updated 7 September 2026