Monitoring questions for independent acute healthcare services

Page last updated: 12 May 2022

During the monitoring call our inspector will focus on these specific key lines of enquiry. You can open the questions to see the type of detail they will be interested in.


S1: How do systems, processes and practices keep people safe and safeguarded from abuse?
  • Are infection risks to people using the service being thoroughly assessed and managed?
  • How are you assured that the layout/environment of clinical and non-clinical areas provides services safely? (for example, clean sites, entrances and waiting areas for known/suspected COVID-19 patients, signage, isolation facilities).
  • Are people using the service being protected from improper treatment, discrimination, and loss of their human rights?
  • Where applicable, has the service identified when they may be depriving a person of their liberty, and followed the correct and lawful procedures (for example Deprivation of Liberty Safeguards application in hospital settings, or Court of Protection)?
  • Are the service’s safeguarding and other policies and practice, together with local systems, properly managing any concerns about abuse and protecting people’s human rights?
  • How do you ensure that staff recognise safeguarding issues for adults, children, and other vulnerable people, and that they take appropriate action?
S2: How are risks to people assessed, and their safety monitored and managed, so they are supported to stay safe?
  • Are risks to the health and wellbeing of people using the service being properly assessed, monitored and managed?
  • Are there enough suitable staff to provide safe care and treatment in a dignified and respectful way? Are there escalation plans in response to surges in demand (for example, a second wave, seasonal pressures?)
  • If there are complications from surgery or deterioration, are there protocols for transferring patients to NHS acute trusts or other appropriate facilities? Does the documented transfer process take account of the design of the facilities/building? (access to the surgical area and safe transfer).
  • How is the service identifying and managing risks for patients including any restrictive practices or issues affecting their legal or human rights?
S3: Do staff have all the information they need to deliver safe care and treatment to people?
  • Is all the information needed to deliver safe care and treatment available to relevant staff in a timely and accessible way? (This may include test and imaging results, care and risk assessments, care plans and case notes.)
  • When people move between teams, services, and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?
  • Is the service able to effectively manage referrals and, where relevant, discharges and ensure safe transfers of care? Where relevant, what are the testing arrangements, and how does the service handle transfers including, where appropriate, urgent emergency transfers?
S4: How does the provider ensure the proper and safe use of medicines, where the service is responsible?
  • Are medicines being managed safely and effectively? Has COVID-19 affected the service’s ability to manage medicines?
  • Where there is no hospital pharmacy on site, is there a service level agreement to support management of medicines?
S5: What is the track record on safety?
  • Are there any significant trends in activity, never events, significant incidents, themes in incidents, mortality, unexpected deaths?
  • Are there any significant trends where groups of patients are doing worse in terms of safety concerns?
  • How are lessons learned, and themes identified? is action taken as a result of investigations when things go wrong?


E1: Are people's needs assessed and care and treatment delivered in line with current legislation, standards and evidence-based guidance to achieve effective outcomes?
  • How is the service identifying, cascading and keeping up-to-date with changes in clinical guidance?
  • In cases where clinicians are performing new, innovative or high-risk procedures, how does the provider ensure they are acting in the patient’s best interest, conveying risks and keeping patients safe?
  • For services that carry out online or remote consultation, how is professional guidance taken into account?
  • Where people are subject to the Mental Health Act, how is the service ensuring compliance with the Act?
E2: How are people’s care and treatment outcomes monitored and how do they compare with other similar services?
  • How is the service collecting information about people's care treatment and outcomes? Where relevant, is the service continuing to submit to relevant national clinical audits?
  • How are outcomes being monitored for groups of people that may be at higher risk, such as people in Black, Asian and Minority Ethnic groups and older people?
E3: How does the service make sure that staff have the skills, knowledge and experience to deliver effective care, support and treatment?
  • How is the service ensuring that all staff have the knowledge, competency, skills, and training to carry out their roles effectively? (This includes medical practitioners working under practising privileges or training programmes.)
  • Where general anaesthesia sedation including conscious/moderate sedation is used, how does the service ensure that practitioners have the skills, knowledge and experience to rescue a patient who becomes inadvertently over-sedated and, where necessary, maintain an airway and establish satisfactory ventilation and oxygenation? (as described in sedation practice for healthcare procedures, Academy of Medical Royal Colleges, 2013).
E4: How well do staff, teams and services work together within and across organisations to deliver effective care and treatment?
  • How is the service ensuring that the necessary staff, teams, and services are involved in assessing, planning, and delivering people’s care and treatment?
  • How does the service ensure that access to an appropriate level of medical advice is available when/if needed?
  • Are there protocols for how multi-disciplinary team meetings are held, and in what circumstances, specifically in relation to cancer services?
  • Where multidisciplinary team working is applicable:
    • Which other organisations do you hold multidisciplinary team meetings with?
    • How do you assure yourself that multidisciplinary team meetings are planned and held with representatives of all teams involved in a patient’s treatment pathway, including with and by external providers?
    • How do you assure yourself the treatment plan agreed by the multidisciplinary team is the one being followed?
    • Where are these meetings recorded and how do you ensure you maintain a contemporaneous set of notes?
    • How do you evaluate the effectiveness of multidisciplinary team meetings?
    • What action do you take if multidisciplinary team meetings are not happening as indicated by national guidance or a patient pathway?
E6: Is consent to care and treatment always sought in line with legislation and guidance?
  • How does the service ensure consent to care and treatment is always sought in line with legislation and guidance? Including, where appropriate:
    • ensuring that people are involved in decisions about not providing care and treatment, including advanced care plans and DNACPR decisions?
    • in services where physical restraint may be necessary, ensuring that it is used in a safe, proportionate, and monitored way as part of a wider person-centred support plan?
    • ensuring staff apply relevant legislation where people may lack capacity to consent to particular care and treatment, including the Mental Capacity Act 2005 (including DoLS in hospital settings) and the Children’s Acts 1989 and 2004?
  • Is your service using an additional consent form that takes account of the risks associated with COVID-19 when carrying out treatment, including elective treatment that is not urgent and may not be medically necessary?


C1: How does the service ensure that people are treated with kindness, respect and compassion, and that they are given emotional support when needed?
  • How does the service support and engage with patients and their families/loved ones?
  • How does the service ensure the care delivered is compassionate and upholds people's human rights?
C2: How does the service support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible?
  • How does the service support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible?
  • Where appropriate, how is the service managing the impact of limited visiting on patients’ wellbeing?
  • Where appropriate, how is the service promoting and ensuring that patients know how to access advocacy support in the absence of ward visits?


R1: How do people receive personalised care that is responsive to their needs?
  • How does the service ensure that it meets the needs of the population served and does it enable flexibility, choice, and continuity of care?
  • Where relevant, do individual patients have choices about how, when and where they are seen?
  • Do patients receive a copy of the GP’s letter, outlining their condition and treatment, in simple language? Is there any move to send letters direct to patients and copy the GP?
R2: Do services take account of the particular needs and choices of different people?
  • How are services delivered, made accessible and coordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances? This may include:
    • ensuring that each patient’s information and communication needs are identified, recorded, flagged, shared and met
    • identifying and making other reasonable adjustments for disabled people
    • meeting the Assessible Information Standard.
  • Where new protocols for admission are being used, how are these being communicated to staff and how are they reviewed to ensure they are non-discriminatory?
  • How does the service make sure that it clearly explains how care is organised? This should include clarifying how consultants are engaged in the private sector, including the use of practising privileges and indemnity, and the arrangements for emergency provision and intensive care.
R3: Can people access care and treatment in a timely way?
  • How is the service managing access to ensure that high-risk patients/pathways are being identified and prioritised appropriately, including re-instating services and handling backlogs?
  • Is there a structured approach to patient flow that ensures all components of the system are appreciated, managed appropriately, and escalated? How does the approach take account of the most up-to-date government advice about COVID-19?


W1: Is there leadership capacity and capability to deliver high-quality, sustainable care?
  • Has there been any impact on leadership capacity as a result of the COVID-19 crisis? Are there plans and mitigations in place if it is affected?
  • Do leaders understand the challenges to quality and sustainability, and can they identify the actions needed to address them?
W3: Is there a culture of high-quality, sustainable care?
  • How is the service taking action to protect the health, safety, and wellbeing of staff? for example, access to emotional support, supporting staff to raise concerns, adequately risk-assessing and placing staff in appropriate environments to protect their health and safety, including staff in Black, Asian and minority ethnic groups, and other staff at a higher risk of COVID-19?
  • Is the service monitoring complaints, including response times and planning improvements as a consequence of upheld complaints? Do patients have the right to mandatory independent resolution of their complaint?
W4: Are there clear responsibilities, roles and systems of accountability to support good governance and management?
  • Is the service able to work effectively with system partners when care and treatment is being commissioned, shared, or transferred?
  • How do the arrangements for reviewing practising privileges and monitoring professional revalidation take account of professional requirements, best practice and legal requirements?
W5: Are there clear and effective processes for managing risks, issues and performance?
  • Does the service have effective systems and methods for monitoring the overall quality of the service and for responding to business risks and issues as they arise? How often are these reviewed, particularly in relation to COVID-19?
  • Does the service have an effective system and method for receiving and disseminating alerts from the MHRA/Central Alert System (CAS)?
  • If a service investigates a healthcare professional’s behaviour and there is a perceived risk to patient safety, what mechanism is put in place to protect patients, communicate concerns with other providers (where the professional works) and other appropriate professional or regulatory bodies?
  • How are infection prevention and control (IPC) systems and processes effectively updated and disseminated to staff?
  • What audit system does the service have in place? Including consultants working under practising privileges, where applicable.
  • How does the service identify themes from complaints and take effective action to investigate and address them?
  • Does the service have valid insurance for its service covering both public and employer liability, including professional indemnity insurance for registered professional staff?