Recurring concern
Failure of care and safety auditing to identify deficiencies
- Reports that mention this concern
- 69
- Times this concern has been raised
- 76
- Stated actions linked to this concern
- 85
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 69 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to conduct sufficiently frequent checks that required records exist and are preserved
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Exemplar Health Care
Stated actions 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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Exemplar Health Care
Digitise EQA governance and establish team-leader accountability, daily management reviews, clinical walkarounds, take-twenty meetings and electronic quality-assurance tracking.
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Exemplar Health Care
Preserve handover records through electronic monthly files, printed management-office copies, archiving and monthly completeness checks.
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Exemplar Health Care
Implement monthly audits of supplementary and care files, with findings discussed with unit managers.
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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Exemplar Health Care
Existing management oversight, quality assurance and governance processes are considered sufficient to ensure records are kept, retained and reviewed for trends.
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Concerns raised1
Lack of a robust audit system for compliance with policies and protocols
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- 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
-
Greater Manchester Mental Health NHS Foundation Trust
Existing supervision and clinical-record audit processes are relied upon to monitor compliance with record-keeping, risk-assessment and review requirements.
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Concerns raised1
Lack of robust audit of compliance with policies for record keeping, risk assessments and reviews
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Greater Manchester Mental Health NHS Foundation Trust
Stated actions 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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Greater Manchester Mental Health NHS Foundation Trust
Conduct quarterly audits of discharge checklists and processes to verify completion and uploading to clinical records.
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Greater Manchester Mental Health NHS Foundation Trust
Require senior staff to review selected clinical notes before supervision sessions.
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Greater Manchester Mental Health NHS Foundation Trust
Conduct quarterly team audits of record keeping and compliance with procedures and clinical risk policy.
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Concerns raised1
Insufficiently robust internal reviews failing to identify and address important patient safety issues
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Inadequate auditing of assessment completion
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of robust management audit of nightly roll checks
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- HM Prison and Probation Service
Stated actions 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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HM Prison and Probation Service
Require a discipline officer to remain on the wing until each night OSG roll check is completed, recorded, signed and reported, with spot checks of compliance.
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HM Prison and Probation Service
Review the quality-assurance processes for roll checks with the LTHSE safety team.
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HM Prison and Probation Service
Visit Belmarsh to identify further roll-check improvements and test compliance with the new process and Local Security Strategy.
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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HM Prison and Probation Service
Routine CCTV monitoring cannot be used to assure roll checks because CCTV is authorised only for specified safety, security or investigative circumstances.
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Concerns raised1
Lack of adequate audit of the Alternative to Transfer service’s net benefit and adverse outcomes
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Department of Health and Social Care
Conduct a full audit of the Alternative to Transfer service to assess whether it delivers safe, high-quality patient care.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Department of Health and Social Care
Clinical commissioning groups are responsible for planning, commissioning, monitoring and assuring local out-of-hours health services.
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Department of Health and Social Care
Existing contract monitoring, eligibility guidance and senior-clinician triage were considered adequate, with no significant concerns identified.
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NHS Greater Manchester Integrated Care Board
Unable to comment on national evaluation of the ATT service, while providing information about local evaluation and monitoring.
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Concerns raised1
Failure to audit education on safe morphine doses
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring 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
Failure to audit patient records for prescribing outside surgery policy
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring 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
Failure of monthly medication audits to detect recording discrepancies
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Pelham house
Stated actions 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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Pelham house
Employ an external auditor to conduct monthly care-plan and medication audits and provide additional advice when needed.
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Pelham house
Conduct monthly medication audits with internal management oversight, visible summaries, and external review of medication administration.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026