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 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.
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
Digitise EQA governance and establish team-leader accountability, daily management reviews, clinical walkarounds, take-twenty meetings and electronic quality-assurance tracking.
Stated by Exemplar Health Care -
Action
Preserve handover records through electronic monthly files, printed management-office copies, archiving and monthly completeness checks.
Stated by Exemplar Health Care -
Action
Implement monthly audits of supplementary and care files, with findings discussed with unit managers.
Stated by Exemplar Health Care
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 management oversight, quality assurance and governance processes are considered sufficient to ensure records are kept, retained and reviewed for trends.
Stated by Exemplar Health Care
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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.
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 supervision and clinical-record audit processes are relied upon to monitor compliance with record-keeping, risk-assessment and review requirements.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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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.
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
Conduct quarterly audits of discharge checklists and processes to verify completion and uploading to clinical records.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Require senior staff to review selected clinical notes before supervision sessions.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Conduct quarterly team audits of record keeping and compliance with procedures and clinical risk policy.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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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.
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
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.
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 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.
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
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.
Stated by HM Prison and Probation Service -
Action
Review the quality-assurance processes for roll checks with the LTHSE safety team.
Stated by HM Prison and Probation Service -
Action
Visit Belmarsh to identify further roll-check improvements and test compliance with the new process and Local Security Strategy.
Stated by HM Prison and Probation Service
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
Routine CCTV monitoring cannot be used to assure roll checks because CCTV is authorised only for specified safety, security or investigative circumstances.
Stated by HM Prison and Probation Service
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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.
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 a full audit of the Alternative to Transfer service to assess whether it delivers safe, high-quality patient care.
Stated by Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Clinical commissioning groups are responsible for planning, commissioning, monitoring and assuring local out-of-hours health services.
Stated by Department of Health and Social Care
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Position
Existing contract monitoring, eligibility guidance and senior-clinician triage were considered adequate, with no significant concerns identified.
Stated by Department of Health and Social Care -
Position
Unable to comment on national evaluation of the ATT service, while providing information about local evaluation and monitoring.
Stated by NHS Greater Manchester Integrated Care Board
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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.
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
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.
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
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.
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
Employ an external auditor to conduct monthly care-plan and medication audits and provide additional advice when needed.
Stated by Pelham house -
Action
Conduct monthly medication audits with internal management oversight, visible summaries, and external review of medication administration.
Stated by Pelham house
Data last updated 7 September 2026