First reported 28 Mar 2013•Latest report 8 Feb 2024
Definition
What this concern includes
Includes failures involving continuity, consistency or cover of staff responsible for ongoing care, including frequent changes of care staff, lack of a stable nursing or medical team, fragmented care coordination, and failure to provide substitute staff during prolonged absence.
Not included
Excludes general staffing shortages, inadequate staffing numbers or excessive workload where continuity of the care team is not the identified unsafe condition.
Excludes failures limited to continuity of treatment, clinical responsibility, information sharing or care planning when staff continuity is not materially involved.
Excludes generic agency-staff reliance, recruitment or retention concerns unless they directly result in unreliable continuity of care staffing.
Excludes continuity failures in non-care functions or services unless the assertion concerns staff responsible for providing ongoing care.
Reports
30
Distinct published reports
Individual concerns
30
A report can raise multiple concerns
Date range
2013–2024
First to latest report issue date
Stated actions
47
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.
Department of Health and Social Care7
NHS England3
Care Quality Commission2
Hull University Teaching Hospitals NHS Trust2
Norfolk and Suffolk NHS Foundation Trust2
North East London NHS Foundation Trust2
Betsi Cadwaladr University LHB1
CSC Computer Sciences Limited1
Delamere Medical Practice1
Dorset Healthcare University NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
HM Prison and Probation Service1
Leicestershire Partnership NHS Trust1
Lincolnshire Community Health Services NHS Trust1
London Borough of Waltham Forest1
NHS trust17
Ministerial department7
Healthcare site4
Executive non-departmental public body3
Integrated care board3
Health and social care service regulator2
Domiciliary care provider1
English unitary authority1
Executive agency1
Health-system partnership1
Local health board1
London borough council1
Private limited company1
Residential care home1
Type not available1
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.
East London
Concerns raised1
Failure to provide continuity of care coordination
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 concerns
Each 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
Action
Deploy semi-permanent agency staff to support community recovery teams during recruitment.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 October 2021.
Action
Recruit additional staff above establishment to reduce care-coordinator caseloads and support relationship building.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 October 2021.
Action
Provide induction training and clinical supervision for permanent and temporary staff managing risks and patient relationships.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 October 2021.
Action
Provide clinical supervisors with a care-coordination prompt covering relationship building, risk management and caseload management.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 October 2021.
Brighton and Hove
Concerns raised1
Insufficient substantive staffing and reliance on bank and agency staff
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Yorkshire Eastern
Concerns raised1
Failure to provide continuity of antenatal care for a high-risk pregnancy
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Leicester City and South Leicestershire
Concerns raised1
Failure to provide continuity of crisis team care
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 concerns
Each 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.8
Action
Recruit 8.5 whole-time-equivalent registered and 12.6 whole-time-equivalent unregistered Crisis Service staff to increase capacity.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019.
Action
Review and revise the Keyworker Standard Operating Procedure to define responsibilities for assessment, care planning, monitoring and discharge planning.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019.
Action
Review the Crisis-to-CMHT discharge process to establish a documented referral and prioritisation process for immediate CMHT allocation.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019.
Action
Implement the revised discharge process, retaining Crisis responsibility until a CMHT appointment is offered and updating crisis and contingency plans with CMHT.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019.
Action
Use rostered assessment-only periods for registered clinicians, with clinicians focusing on treatment outside those periods, to increase treatment capacity and continuity.
Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Audit Crisis patients open between September 2018 and September 2019 to assess staff bands and visit continuity by the end of November 2019.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019.
Action
Develop a continuity-of-care improvement plan informed by the Crisis Service continuity audit.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019.
Action
Review local staff guidance on pre-visit preparation, including prior-entry, risk-assessment, outstanding-action and communication-needs checks.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019.
Portsmouth and South East Hampshire
Concerns raised1
Lack of continuity of care in antenatal appointments
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 concerns
Each 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
Action
Establish two continuity-of-carer pathway teams providing named midwives and buddies throughout antenatal, birth and postnatal care.
Stated by Portsmouth Hospitals University NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 September 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Handheld notes, scheduled checks and trained midwives are considered sufficient to identify and escalate pregnancy abnormalities despite lack of continuity.
Stated by Portsmouth Hospitals University NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Norfolk
Concerns raised1
Failure to provide continuity in the number of staff involved in care
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 concerns
Each 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
Action
Apply the national 39-point fidelity scale across the Trust to identify improvement areas and consistently match clinicians with patients using daily planning.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The CRHT cannot guarantee that service users will see a limited number of staff because intensive support requires flexible 24/7 staffing.
Stated by Norfolk and Suffolk NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Lack of continuity of care preventing a clinician from maintaining an overview of the patient and her health
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 concerns
Each 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
Action
Review clinical staffing numbers and clinical sessions to support patient continuity and existing staff.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Buckinghamshire
Concerns raised1
Failure to maintain continuity of engagement and care during key staff changes and sickness absence
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Nottinghamshire
Concerns raised1
Failure to ensure consistency and continuity of care
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 concerns
Each 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
Action
Introduce the Modified Modified Continuity Index into routine reporting, trial it in one team, and then implement it across Crisis Teams.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 February 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Continuity of staff cannot always be provided because 24-hour crisis response requirements and high-intensity care create operational constraints.
Stated by Nottinghamshire Healthcare NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester North
Concerns raised1
Lack of continuity in medical care
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 concerns
Each 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.2
Position
Mrs Parker was seen by three junior doctors, not seven.
Stated by Northern Care Alliance NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Multiple clinicians are normal practice because specialist input and full handover provide appropriate continuity of care.
Stated by Northern Care Alliance NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures involving continuity, consistency or cover of staff responsible for ongoing care, including frequent changes of care staff, lack of a stable nursing or medical team, fragmented care coordination, and failure to provide substitute staff during prolonged absence.
