Care home incident, audit systems
Systems for audits, incidents, and accidents monitoring in care homes are not fully embedded or mature.
Source spread
Where this theme appears
This theme appears across 12 independent accountability sources, so the source mix matters as much as the headline total.
4 inquiry recs
61 PFD reports
1 committee rec
91 CQC actions
1 IMB rec
1 detention investigation rec
9 DHR recs
14 PHSO decisions
199 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(4)
R66 — Quarterly safeguarding file audit
Recommendation: A quarterly multidisciplinary audit of 10% of safeguarding files per ward or residential unit should be conducted. Findings must be integrated with incident data and reported to the Executive Team, NEDs and the Strategic Planning and Performance Group (SPPG).
No response yet
R45 — Incident trend analysis on board dashboards
Recommendation: Incident reports of any violent or aggressive behaviour by either people with learning disabilities and autistic people or staff should be analysed and trend data reported on every HSCT Board’s quality and safety dashboard. In private and third sector care …
No response yet
R73 — OCT report detail sufficiency
Recommendation: Health Boards should ensure that OCT reports provide sufficient details of the key factors in the spread of infection to allow a proper audit to be carried out, as recommended in the Watt Group Report.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R78 — Audit committee implementation tracking
Recommendation: HSCT Board audit committees should consider all internal audit recommendations and require directorates to provide updates on implementation three months, six months and one year after the internal audit report is received, and three monthly thereafter if still not fully …
No response yet
Prevention of Future Deaths reports(61)— showing 50 strongest matches
Derrick Rivers
Concerns: The coroner identified inadequacies in the care home's drug administration policy and audit processes, which were not fully noted by the Local Authority or CQC during inspections. Concerns were also raised about management's awareness of staff not following protocols and delayed action on recommendations.
Overdue
Peter Furness
Concerns: The care home lacks a documented process for escalating incidents or concerns to trigger multi-disciplinary team meetings that review risk assessments and care plans for vulnerable residents.
Response (Nant Y Gaer Hall): • Nant Y Gaer Hall implemented a new alert system for escalating changes in residents' conditions and behaviours. • The new system includes a clear process, policy documents, flow charts, … (AI summary)
Responded
Jean Gillespie
Concerns: The coroner identified that a senior care staff member administering medication was unaware of a resident's life-threatening condition and its urgency. Care home records lacked information on the condition, its symptoms, and the purpose of prescribed medication, presenting a risk if replicated.
Response (MMCG): • Senior Care Assistants received further medication training and competency assessments. • Supervisions were completed to reinforce medication management policies and procedures. • A new manager introduced handover sheets and … (AI summary)
Responded
Marie Quinn
Concerns: The coroner identified concerns regarding medication management at Richmond House Nursing Home, where excess medication was not queried. Inaccurate hospital discharge notes led to the premature cessation of prophylaxis treatment for a patient.
Overdue
Rebecca Gilbank
Concerns: The coroner noted insufficient staff resources led to missed checks for service users, and staff lacked knowledge on how to obtain an outside telephone line for emergency calls, causing a delay.
Response (Independence Homes): • The organisation changed its telephone contract to remove the requirement to dial 9 for an outside line. • The change was communicated to staff verbally, by email, and in … (AI summary)
Responded
Norman Beard
Concerns: The coroner identified poor management, a lack of clear policies, and staff and resource shortages due to financial difficulties. Concerns also included delayed referrals for a resident's pressure ulcers and weight loss, and insufficient follow-up on medical advice.
Overdue
Robert Davidson
Concerns: Healthcare staff lacked training in basic emergency procedures, including 999 calls and CPR, and Health Care Assistants had insufficient foundational training for their role. The deceased's PICA behaviour was also not highlighted during care home transfer.
Response (Priory Group): • The incident and lessons learned regarding effective communication during resident transfer will be raised in a forthcoming quarterly Safety 1st bulletin. • The requirement for staff to complete Form … (AI summary)
Response (Avery): • Avery stated it has established systems for staff training on emergency procedures and comprehensive documentation for patient information transfer. • Avery confirmed it has robust recruitment and induction processes … (AI summary)
Response (NHS England): • The response noted the introduction of the National Care Certificate, developed jointly by Health Education England, Skills for Health, and Skills for Care. • The National Care Certificate establishes … (AI summary)
Response (CQC): • CQC inspections in March and November 2016 at Aran Court Care Centre identified systems for emergency first aid training for nurses and confirmed staff understanding of 999 call procedures. … (AI summary)
Response (Department of Health): • The Government introduced the Care Certificate in April 2015, which includes standards for basic life support and health and safety. • The Department of Health is investing £12m in … (AI summary)
Responded
Geoffrey Spencer
Concerns: The coroner noted a lack of formal investigation into Mr Spencer's serious injury, which reduced the potential for learning and improving safety for other residents, despite general improvements to the facility's falls policy.
Response (The Lakes Care Centre): • The Lakes Care Centre undertook a complete investigation into the incident. • The centre reviewed and changed work patterns to optimise resources and enhance safety. (AI summary)
Responded
Sheila Ross
Concerns: The report is incomplete and does not contain any specific concerns from the coroner.
Overdue
Mildred Griffiths
Concerns: The care home's Braden Score for pressure sore risk may underestimate risk by not accounting for existing lesions and causes confusion due to its inverse calculation compared to the nationally recognised Walsall score.
Response (Avery Health Group): • The organisation conducted a root cause analysis in the specific case. • The organisation stated it would continue to use the Braden pressure ulcer risk tool. • The organisation … (AI summary)
Responded
David Sketchley
Concerns: The report identifies concerns regarding the quality of the BUPA investigation, which did not conclude on supervision levels or commode suitability. It also notes an absence of evidence that BUPA's practice reflects care service standards for commode assessments.
Response: • The Medicines and Healthcare products Regulatory Agency (MHRA) stated that commodes are not regulated as medical devices in the UK. • The MHRA will continue to pass reports of … (AI summary)
Overdue
Lea Hunsley
Concerns: The EAM facility lacked a serious untoward incident protocol, and staff demonstrated insufficient ability to identify deteriorating patients, escalate medical reviews, or use care records effectively. Insufficient action had been taken on recommendations from a CQC inspection, without sustained improvement.
Response (EAM Care Group): • A Serious Untoward Incident Reporting Policy and a Duty of Candour policy have been implemented. • Staff have undertaken clinical observation training, and nurse managers have been trained to … (AI summary)
Responded
George Goldby
Concerns: The coroner identified that care home staff were unaware of and did not follow SALT recommendations for resident supervision and dietary needs, leading to unsupervised mealtimes for those at high choking risk. Concerns also included inadequate incident reporting and disorganised care plan records.
Response (HC One): • HC One conducted a full review of systems and processes, leading to re-planning of individual resident care and the allocation of an Operational Project Manager. • The home implemented … (AI summary)
Responded
Sophie Bennett
Concerns: Inadequate governance was identified at Lancaster Lodge, including the lack of a registered manager, insufficient trained staff, and poor controls on resident documentation. The coroner also noted grossly inadequate leadership and oversight by the Board, impacting employment and communication procedures.
Overdue
Ruth Gregory
Concerns: The coroner noted that residents were regularly unsupervised in communal care home areas, creating a risk of resident-on-resident incidents leading to trauma. Information on risk management and supervision arrangements was absent.
Response (Borough Care): • The organisation increased staffing levels across its homes in January 2018. • Day shifts now include eight staff, comprising a deputy manager and senior carer. • Night shifts now … (AI summary)
Responded
Patrick Kelly
Concerns: Roseberry Care Centres did not adequately prioritise dental hygiene or dental service provision for residents, which potentially worsened a dental abscess. There were also insufficient policies for managing missed dental appointments and identifying when appointments were required.
Response (Roseberry Care): • The organisation implemented a 'Resident of the Day' procedure for monthly care plan reviews and updates, including resident and/or relative involvement. • A diary record was implemented to track … (AI summary)
Responded
Yong Hong
Concerns: Concerns included the care home's failure to implement a GP-advised observation regime and to conduct a risk assessment before returning a call bell. There was also a lack of an interpreter for mental health assessment due to funding confusion, and staff lacked training.
Overdue
Margaret Melia
Concerns: Inadequate discharge and pre-assessment processes between two care homes meant that the patient's requirement for subcutaneous fluids was not properly managed.
Response (HC One): • HC-One updated its Admission, Transfer and Discharge Procedure to require further information seeking if a pre-assessment was completed more than five days prior to admission. • These procedural changes … (AI summary)
Overdue
Dylan Henty
Concerns: The coroner noted a lack of clear guidance and training for staff regarding residents with seizure risks bathing unsupervised, and insufficient reporting of incidents like hoarding, medication non-compliance, and absconding to relevant professionals and bodies.
Response (Pentree Lodge Care Home): • The home committed to encouraging assisted bathing for residents with seizure risk, developing care plans with specialist nurse advice, and providing staff training. • It reviewed its medication procedure, … (AI summary)
Responded
Arnold Ward
Concerns: The care home's forms did not adequately capture pressure ulcer deterioration, leading to a delay in recognition and escalation to the Tissue Viability Nursing team, and there was no system to chase up referrals.
Response (Stockport NHS): • Fernlea Nursing Home implemented the use of photographs and a new monitoring form to track pressure ulcer development. • The referral process to the Tissue Viability Nursing Team was … (AI summary)
Response (CQC): • The CQC commenced an unannounced, focused inspection of Fernlea Care Home on 27 January 2020. • The CQC investigated whether the registered provider had failed to submit a statutory … (AI summary)
Response (Fernlea Care Home): • The care home arranged wound management refresher training for Registered Nurses and care staff, incorporating it into the induction program. • The care home adopted the NHS wound management … (AI summary)
Responded
Barry Liffen
Concerns: The coroner noted a need for clinical assessments for frail residents at Glebelands following falls and for any residents whose health deterioration was observed by staff.
Response (Borough Care Ltd): • Home managers will review falls weekly using the Person Centered Software system, documenting actions in falls logs and resident support plans. • A review with a GP or CPN … (AI summary)
Responded
Keith Whetton
Concerns: The coroner identified a delay in seeking medical attention for Keith on 8th September and a lack of timely communication with family members regarding his fall.
Response (Hunters Lodge Care Centre): • Staff received supervision and completed falls training. • The falls policy and procedure was updated and implemented. • Staffing levels were increased to enhance resident observation and nursing support. (AI summary)
Responded
Elaine Renshaw
Concerns: The coroner noted insufficient processes for managing controlled drugs in care and nursing homes, leading to difficulties in accounting for medication and inaccurate stock sheets.
Overdue
Norman Baxter
Concerns: The inquest determined that a hip fracture sustained in hospital, which ultimately necessitated a girdlestone procedure, likely contributed to the individual's death.
Response (Lynmere Nursing Home): • Lynmere Nursing Home implemented the NEWS Scoring System, NEWS 2 Charts, and sepsis management algorithms and guidance. • One-to-one discussions were held with all nursing staff to confirm their … (AI summary)
Responded
Peter Howarth
Concerns: Borough Care did not investigate the circumstances of a resident's fall that led to his hospital admission. The coroner noted that robust investigations into falls are essential for learning and reducing the risk of future deaths.
Response (Borough Care): • Borough Care implemented new procedures for reviewing falls across its homes. • Managers are now required to complete weekly falls analyses and monthly reviews to identify trends. • The … (AI summary)
Responded
Edward Mallaby
Concerns: The care home lacked a clear policy for handling residents' hazardous personal property, and a sensor mat failed to alert staff to the deceased being out of bed. There was no rapid learning exercise after the incident, and policy reviews lacked completion deadlines.
Response (Roseberry Care Centres): • Updated policies concerning residents' belongings, admission, and falls management were issued across all care centres, with staff at Alexandra View completing supervision sessions on these by 31st December 2020. … (AI summary)
Responded
Marion Glover
Concerns: The care home design allows residents with cognitive illnesses to freely leave the building unnoticed, as the main exit is unlocked during the day and there is no observation of the foyer area. This raises concerns about the suitability of the accommodation for individuals with such conditions.
Response (Able Care and Support Services Ltd): • The organisation confirmed the implementation of enhanced pre-admission risk assessments for new tenants, including those with cognitive illnesses and confusion. • It stated that scheduled annual reviews of resident … (AI summary)
Responded
Clara Freeman
Concerns: The coroner identified gaps in the proficiency of care and nursing staff regarding post-fall patient management, including interaction with ambulance services and accurate recording of vital signs. A review of staff training on these areas and awareness of fall complications is recommended.
Response (Hart Care): • Hart Care confirmed that all staff members in charge of shifts attended First Aid Training in May 2021. • The First Aid Training covered managing falls, calling emergency services, … (AI summary)
Responded
Rachel Johnston
Concerns: The coroner noted Pirton Grange lacked a robust policy for investigating staff misconduct, including imposing suspensions and reporting to the NMC. Following a death, initial investigation and reporting of nurse conduct to the NMC were inadequate and delayed.
Response (Holmleigh Care Homes Ltd): • The Home engaged a solicitor's firm to provide independent oversight and advice on HR matters, investigations, disciplinary actions, and professional body reporting. • The Home appointed a new Registered … (AI summary)
Overdue
Pauline Brumfitt
Concerns: The care home did not apply its falls risk assessment and prevention policies, missing opportunities to reassess the resident's risks after three falls. There was a lack of timely reporting to regulatory bodies and delayed commencement of staff supervision regarding falls prevention.
Response (Anchor Hanover Group): • Disciplinary proceedings were initiated against staff involved in reporting failures, resulting in a manager's resignation and a Disclosure and Barring Service referral. • A detailed individual falls tracker was … (AI summary)
Overdue
Catherine Jux
Concerns: A patient's risk assessment was not completed within 24 hours of admission to Elvy Court Nursing Home, and staff did not identify this oversight. The home lacked an adequate process for auditing the completion of such assessments according to its policy.
Response (Elvy Court Nursing Home): • The home utilises an electronic system with RAG-rated alerts to inform users of pending or overdue reviews for clinical assessments and care plans. • A five-day audit is conducted … (AI summary)
Overdue
Eldine Lashley
Concerns: The coroner noted that Mrs Lashley's mobility care plan was not updated to reflect the need for more frequent observation, and progress notes by staff did not accurately record the frequency of checks performed.
Overdue
Tripta Bhanote
Concerns: The coroner noted a lack of clarity among care staff regarding when to escalate acutely unwell residents to emergency services and the role of the enhanced care team. There were also poor procedures for identifying residents' DNAR status.
Overdue
Henry Doll
Concerns: The coroner noted that managers misunderstood and inaccurately completed risk assessments, leading to concerns that risk screenings for other residents in the Avenues Group may also have similar inaccuracies. This suggests a need for improved understanding and training regarding the risk assessment process.
Overdue
Colm McCabe
Concerns: The coroner identified gaps in policy adherence, staff recruitment, training, and appraisals at the care home. Concerns were also raised regarding the effectiveness of auditing processes and the candour of internal investigations.
Response (Four Seasons Healthcare Group): • The Group introduced a 'Policy of the Month' and improved its training platform, recruitment processes, and supervision and appraisal framework. • The Group is developing bespoke training for Home … (AI summary)
Overdue
Dorothy Spiby
Concerns: The coroner noted an unclear account of a resident's fall at Tamworth Court Nursing Home, with no incident recorded in nursing notes, no incident form completed, and no investigation or evidence of learning from the event.
Response (Prime Life Ltd): • Prime Life Ltd delivered training to nurses on defensible documentation and incident form completion, and to all staff on clear and concise record keeping. • The home management team … (AI summary)
Responded
Margaret Greenacre
Concerns: The coroner noted delays in statutory notifications of incidents to the CQC, including one that was never reported, potentially hindering investigations. Concerns were also raised regarding poor record-keeping at the care home, where care notes did not accurately reflect residents' needs and care plans were not updated.
Response (Alcyone Healthcare): • The care home is transitioning to a new provider and management team. • The new management team stated it would implement new compliance systems, reporting processes, and care planning … (AI summary)
Responded
Karen Redding
Concerns: The coroner noted that care staff provided Oramorph without checking its contents and that a medical review might have been appropriate after the individual disclosed taking an excess dose.
Response (Cherish Home Care Ltd): • The organisation implemented a new procedure requiring staff to seek medical assistance for medication overdoses, irrespective of service user or family wishes. • Medication policies and procedures were reviewed … (AI summary)
Responded
Shona Campbell
Concerns: The coroner identified issues with inadequate contemporaneous clinical record-keeping and communication among staff, along with incomplete patient observations and care plans. Further concerns noted patients' access to ligatures, insufficient staff training and supervision, and a lack of clear clinical assessment for repeated self-harm attempts.
Pending
Beryl Ellison
Concerns: The report raises concerns about Alexandra Care Home's medication management and supervision, with no explanation for the excessive oxycodone found in Mrs Ellison, and the systems remaining unchanged since her death.
Response (Four Seasons Health Care Group): • The Group reviewed and refreshed its medication competency assessment, reissuing it to all care homes and enhancing training requirements for staff. • A new dependency tool, DepenSys, was implemented … (AI summary)
Responded
Jennifer Rackley
Concerns: The coroner noted insufficient falls prevention for a high-risk patient due to bed placement and a single sensor mat. Concerns also involved the lack of written records for an incident investigation and the manager's inability to identify involved staff.
Overdue
Irene White
Concerns: Frome Nursing Home staff did not adequately assess or manage the risk of deep vein thrombosis for an immobile patient, lacking a DVT policy and failing to inquire about care needs or implement preventative measures.
Overdue
Sylvia Nash
Concerns: The coroner notes a lack of clear understanding among agencies regarding the process for deciding on the removal of 1:1 patient observations, with disagreement between the Council and the care home on who holds responsibility. This indicates insufficient communication and understanding of the correct process between involved parties.
Response: • The respondent noted that the ICB has implemented a new process for 1:1 observation removal, requiring discussion between the reviewer, Care Home Nurse, and Social Worker. • The respondent … (AI summary)
Response: • Connaught House stated it did not remove 1:1 observations for the resident and continued to provide this care. • Connaught House stated it consistently communicated its assessment of the … (AI summary)
Response (Birmingham City Council): • Birmingham City Council (BCC) held staff engagement sessions and implemented a new template for social workers to record multi-disciplinary decision-making, agreed actions, and risk mitigations. • BCC worked with … (AI summary)
Responded
Victor Costello
Concerns: Ineffective communication within the nursing home meant staff on duty were unaware of family concerns regarding Mr Costello, who was nil-by-mouth but reported drinking tap water.
Response (Stockton Care LTD): • Staff were informed of the coroner's concern regarding communication, and an all-staff meeting was held on 22 March 2024. • An upgraded cloud-based electronic documentation system is being implemented, … (AI summary)
Responded
Frederick Boyd
Concerns: The coroner identified a lack of clear systems for quality checks on unwell residents, limited documentation, and an unclear escalation process not understood by staff.
Response (Lakes Care Centre and CQC): • The CQC initiated an assessment of The Lakes Care Centre on 22 April 2024, identifying breaches of Regulations 12, 18, and 17. • The CQC will require the registered … (AI summary)
Responded
Sylvia Prichard
Concerns: The coroner raised concerns about out-of-date mobility care plans, a lack of falls minimisation plans, and significant delays in call bell response times at the care home. The report also identified limited provision of emergency alert devices and insufficient corporate oversight.
Response (Avery Healthcare Group): • The care home completed a full audit of all residents' care plans, introduced a Care Plan Tracker, and ensured all residents at risk of falls have minimisation plans. • … (AI summary)
Responded
Sheila Nicholls
Concerns: The coroner identified deficiencies in policy management, including relevance, version control, and ensuring staff comprehension. Concerns were also raised about inadequate emergency response training for staff and the quality of adverse incident investigations.
Response (Mandeville Grange Nursing Home): • The care home engaged an external company to rewrite all policies, establishing a new process for drafting, review, distribution, and monitoring. • It transitioned the majority of staff training … (AI summary)
Responded
James Siddons
Concerns: The coroner noted flaws in Mills Family Ltd's investigation into a patient's fracture, including a lack of detailed guidance and training for managers on conducting investigations. There was also a delay in the London Borough of Bromley's request for a provider-led report.
Response (London Borough of Bromley): • A discussion was held with the social worker involved to highlight the importance of timely handling of safeguarding concerns, including Provider Lead Enquiries (PLEs). • Processes have been implemented … (AI summary)
Response (Mills Family Ltd): • The organisation re-emphasised to managers and deputy managers the notification of serious incidents to senior management and the requirement for Director of Care input on investigation reports. • New … (AI summary)
Responded
June Phillips
Concerns: The coroner identified concerns regarding inaccurate care home records not reflecting a patient's deterioration, the failure to update the falls risk assessment after a fall, and an inadequate post-falls investigation.
Response (Willow Grange Care Home): • A root analysis tool and an incident investigation form have been implemented. • The policy for residents on blood thinners who fall has been updated, requiring 999 to be … (AI summary)
Responded
Javed Iqbal
Concerns: The coroner noted a continuing risk that care staff may not recognise and take appropriate action for serious acute mental health issues, citing examples of inaccurate record-keeping and a care co-ordinator not actioning a GP's request for written concerns.
Response (All Care In One Ltd): • The company appointed consultants to oversee staff, monitor compliance, and support the implementation of training changes. • Staff completed safeguarding training, including modules on identifying early signs of mental … (AI summary)
Responded
NCEPOD recommendations(1)
CQC inspection actions(91)— showing 50 strongest matches
Royal Victoria Infirmary
The service must ensure there are clearly defined assurance processes, including audits, and that all staff are aware of the required frequency and recording of these.
Must Do
Royal Victoria Infirmary
The service must assess, monitor, and improve the quality and safety of the services provided in the carrying on of the regulated activity.
Must Do
Royal Victoria Infirmary
The service must ensure systems and processes are established and operated effectively to assess, monitor and improve the quality and safety of the services provided in delivery of regulated activities, in line with national guidance and frameworks.
Must Do
Royal Victoria Infirmary
The trust must ensure that all premises and equipment are clean, secure, suitable for the purpose for which they are being used, properly used and properly maintained. This includes but is not limited to daily checks of emergency equipment and …
Must Do
Royal Sussex County Hospital
The trust should improve systems for monitoring induction compliance and oversight.
Should Do
Royal Hallamshire Hospital
The trust must ensure audit information is up to date, accurate and properly analysed and reviewed by people with the appropriate skills and competence to understand its significance.
Must Do
Royal Hallamshire Hospital
The trust must continue to improve and embed processes for investigating serious incidents.
Must Do
Northampton General Hospital
The trust should ensure systems were in place to ensure audits were consistently reviewed and actions taken to address any identified concerns.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurethereareclearandavailablecleaningrecordsinplace.
Should Do
St Benedict's Hospice
The service should ensure it can demonstrate participation in all national level audits.
Should Do
King's Mill Hospital
When issues are identified from audits action is taken further auditing cycles are undertaken to demonstrate if improvements and changes in practice have improved patient outcomes and improved practice.
Should Do
King's Mill Hospital
The trust should continue to implement their new electronic system. To support auditing the quality of the service.
Should Do
Royal Sussex County Hospital
The trust should ensure that patient records are audited for quality.
Should Do
Royal Sussex County Hospital
The trust should ensure hand hygiene audits are consistently completed.
Should Do
Royal Sussex County Hospital
The trust should strengthen and create more robust audit processes to obtain more reliable, valid and accurate data, particularly regarding hand hygiene and environmental cleanliness standards.
Should Do
Durham Diagnostics and Treatment Centre
The service must ensure a robust audit plan is in place and key audits are conducted, including record keeping, medicines management and infection prevention and control audits. The service must ensure relevant actions identified by local audits are acted on.
Must Do
Durham Diagnostics and Treatment Centre
The service must ensure all staff are engaged with and participate in all steps of the World Health Organisation (WHO) surgical safety checklist, the checklist is fully completed, and observational and record audits are undertaken to monitor compliance.
Must Do
Durham Diagnostics and Treatment Centre
The service must ensure a robust audit plan is in place and key audits are conducted, including record keeping, medicines management and infection prevention and control audits.
Must Do
Verve Health
The service must ensure service user safety incidents are managed, staff report incidents appropriately and managers investigate incidents and share lessons learned with the whole team.
Must Do
Suite 4, Jason House
The provider must ensure audits carried out are effective.
Must Do
Roky Care Ltd
The provider must ensure effective auditing systems are in place to identify areas of improvement.
Must Do
Sunderland Royal Hospital
The trust must implement an effective system to assess, monitor, and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service in line with the regulations
Must Do
Royal Victoria Infirmary
The trust must ensure that risks recorded at corporate level and in the board assurance framework are current and have clear actions for mitigation which can be monitored and measured.
Must Do
Royal Victoria Infirmary
The trust must ensure it encourages the identification, reporting and investigation of incidents and risks in a timely fashion and shares learning to improve safety and quality of the service.
Must Do
Royal Hallamshire Hospital
The trust must ensure that serious incidents are reported and investigated in a timely manner in line with national guidance.
Must Do
Royal Hallamshire Hospital
The trust must ensure that serious incidents are reported and investigated in a timely manner in line with national guidance.
Must Do
Northern General Hospital
The trust should ensure epidural wait times are monitored and audited in line with national guidance.
Should Do
Northern General Hospital
The trust should consider expanding the audit programme to include the assessment of pain and the use of preoperative fasting.
Should Do
Northern General Hospital
The trust should consider expanding the existing audit schedule to include the assessment of pain.
Should Do
Northern General Hospital
The trust should consider methods to introduce a consistently applied audit schedule.
Should Do
Northern General Hospital
The trust must ensure audit information is up to date, accurate and properly analysed and reviewed by people with the appropriate skills and competence to understand its significance.
Must Do
Montagu Hospital, Mexborough
Thetrustshouldhaveaneffectiveprocesstoreviewperformanceandmanagerisksateachhospitalsite.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldhaveaneffectiveprocesstoreviewperformanceandmanagerisksateachhospitalsite.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurestaffreportincidentsfollowingtheiroccurrence.
Should Do
Montagu Hospital, Mexborough
ThetrustshouldensurethatIamcleanstickersaredated.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatlegionellatestingrecordsconfirmwhatactionsweretakenwhenlegionellawaspresent.
Should Do
Montagu Hospital, Mexborough
Thetrustmustensurethatallstaffunderstandthetrustsincidentreportingsystemandthatincidentsarereportedconsistentlyandappropriately.Regulation12(2)(b)
Must Do
Ellesmere Port Hospital
The trust must implement effective systems to comply with the requirements of CQC registration. The system must ensure services are provided from locations which have appropriately added to the trust’s registration.
Must Do
Doncaster Royal Infirmary
The trust must ensure there are effective systems and processes to identify where quality and safety are being compromised and to respond appropriately and without delay. It must ensure it improves its clinical audit processes and systems. It must continue …
Must Do
Croydon University Hospital
The trust should ensure equipment including emergency equipment are regularly maintained and checked in line with trust policy.
Should Do
Castle Hill Hospital
The service must ensure systems are in place to ensure equipment is serviced and COSHH chemicals are appropriately and securely stored.
Must Do
St Benedict's Hospice
The service should ensure staff maintain all clear stickers to reflect the last calibrated and tested documentation in line with their process.
Should Do
King's Mill Hospital
The trust must ensure they implement a robust system in maternity triage to include escalation process, monitoring and documentation.
Must Do
Dorset County Hospital
Theservicemustensureaneffectiveandcomprehensive,rollingprogrammeofauditisinplace,andresultsare monitoredforusetoimproveservices.Thisincludesbutisnotlimitedtoeffectivemonitoringofwaittimesand appropriatecareinmaternitytriage,andthequalityofrecordkeeping.
Must Do
Unit 4 Cornishway Industrial Estate
Ensure incidents that affect the health, safety and welfare of people using services are appropriately recognised and reported. Incidents must be reviewed and thoroughly investigated by competent staff and monitored to make sure that action is taken to remedy the …
Must Do
Orton Manor Nursing Home
Implement overall analysis of accidents and incidents to identify any trends or patterns.
Should Do
Oak Tree Manor
Accidents and incidents needed to have remedial actions taken recorded and a system for identifying themes and trends needed to be developed to ensure it was robust.
Should Do
Copperfields Residential Home
There are audit processes and other systems in place but these are not robust enough to assess, monitor and continually improve the service.
Must Do
Aspirations (Northampton)
not all audits had been completed within the timescale set out by the provider. For example, we found not all infection control audits had been completed monthly as per the providers procedure.
Should Do
Aaron Abbey Care Services Limited
The registered manager's systems and processes to monitor quality and safety in the service were not established and operated effectively to ensure compliance with their legal requirements. This was a continued breach of Regulation 17 of the Health and Social …
Must Do
IMB individual recommendations(1)
Health investigations(16)
Independent investigation: Phyllis Deane, Shaldon/Torquay Devon (2007) — Rec 13
A robust annual audit plan, reflecting the Clinical Practice Standards and the standards specified in ‘Services Good Enough for My Family’, needs to be developed and widely disseminated. This will need to detail the roles and responsibilities of team leaders and managers not just in terms of data collection but …
south_west
Independent investigation: Jenny Bryant, Consett — Rec 2
This case highlights the importance of having a clear and structured risk assessment and management process within a care home environment. MR’s care home had an incident reporting system in place, as well as a process for reviewing reported incidents. However, the assessment of risk potential and how this was …
north_east_yorkshire
Independent investigation into the care and treatment of MR: Published … — Rec 2
This case highlights the importance of having a clear and structured risk assessment and management process within a care home environment. MR’s care home had an incident reporting system in place, as well as a process for reviewing reported incidents. However, the assessment of risk potential and how this was …
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Colin … — Rec 17
Within the care home there were occasions when clinical policies and procedures were not complied with. Anisha Grange Care Home must ensure that the monitoring mechanisms within the following policies/procedures (or their equivalent) are achievable and being complied with, and that all policy/procedures continue to be subject to regular audit …
east_of_england
An independent investigation into the care and treatment of Colin … — Rec 16
Incidents were not always reported in line with regulations and to facilitate a comprehensive investigation to be undertaken. Woodland View Care Home must ensure that the following policy is subject to regular audit or testing and staff trained in its use to ensure that required outcomes for patients and their …
east_of_england
An independent investigation into the care and treatment of Colin … — Rec 15
Within the care home there was inconsistent application of the Mental Capacity Act which requires decision specific assessments of capacity. Woodland View Care Home needs to ensure that key aspects of the Mental Capacity Act are subject to regular audit or testing and staff trained in its use to ensure …
east_of_england
An independent investigation into the care and treatment of Colin … — Rec 14
Within the care home there were occasions when clinical policies and procedures were not complied with. Woodland View Care Home must ensure that the monitoring mechanisms within the following policies/procedures (or their equivalent) are achievable and being complied with, and that all policy/procedures are subject to regular audit or testing …
east_of_england
Independent investigation: Mark Berry, Dewsbury (2005) — Rec Recommendation
The Trust should ensure that it implements and monitors its current Incident Management Policy to ensure clarity of goals and processes to be followed, including the adoption of SMART criteria for the recommendations of any future internal reviews. An audit of the policy should be done on an annual basis …
north_east_yorkshire
Independent investigation: Bianca ‘Kay’ Shepherd, Uxbridge (2015) — Rec 4
The CCG should undertake an audit of Serious Incidents within the past 12 months with a view to confirming that action plans were monitored and tested.
london
Independent investigation: Bianca ‘Kay’ Shepherd, Uxbridge (2015) — Rec 3
The CCG should assure itself within the next three months that it has robust systems and processes in place to monitor and test individual SI action plans. This should include finalising its SOP for the ‘internal management of Serious Incidents utilising “Datix”’
london
*Mental health homicide investigation legacy report into the care and … — Rec 5
The Trust should conduct an audit to ensure compliance with National Patient Safety Agency Independent Investigations of Serious Patient Safety Incidents in Mental Health 2008
south_east
Independent investigation into the care and treatment of Mr S — Rec 4
The CCG should undertake an audit of Serious Incidents within the past 12 months with a view to confirming that action plans were monitored and tested.
london
Accepted
Independent investigation into the care and treatment of Mr S — Rec 3
The CCG should assure itself within the next three months that it has robust systems and processes in place to monitor and test individual SI action plans. This should include finalising its SOP for the ‘internal management of Serious Incidents utilising “Datix”’
london
Accepted
Independent investigation: Phyllis Deane, Shaldon/Torquay Devon (2007) — Rec 12
The implementation of the Clinical Practice Standards and the Practice Quality Audit needs to be strengthened across the Trust. Clinical audit participation needs to be developed through: being a standing item on all clinical team meeting agendas being included in individual annual appraisal and personal development plans being monitored through …
south_west
Independent investigation: Antonio Tommaso, New Barnet (2014) — Rec 3
The Trust undertakes a detailed and comprehensive audit of the safety and security of the Sussex ward.
london
Independent investigation into the care and treatment of Mr L — Rec 4
The Trust must assure itself that risk assessments and risk management plans are reviewed when new information comes to light. The Trust must also implement an ongoing audit programme to provide assurance about organisational compliance with this requirement.
L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Independent reviews(2)
Francis Inquiry (Mid Staffs 2010) — Rec 5
The Board should institute a programme of improving the arrangements for audit in all clinical departments and make participation in audit processes in accordance with contemporary standards of practice a requirement for all relevant staff. The Board should review audit processes and outcomes on a regular basis.
Health & Social Care
Ockenden Review — Rec LAfL 14.18
Improving Audit Process There must be midwifery and obstetric co-leads for audits.
Health & Social Care
PHSO casework decisions(14)
P-003058 — Care Quality Commission
Mr and Mrs B complained the CQC failed to properly inspect a nursing home, act on intelligence, communicate effectively, follow enforcement policy, and resolve their complaints, causing distress.
UK Government
Partly Upheld
Oct 2024
P-002389 — An independent provider in the Redcar and Cleveland …
Miss Y complained a care home left Mr Y unconscious on the floor, provided incorrect nutrition, failed to test urine, lost glasses, and did not provide footwear. This allegedly worsened his health.
NHS in England
Aug 2023
P-003732 — Mid and South Essex NHS Foundation Trust
Mr M complained his mother developed eight pressure sores during her hospital admission and was discharged with them, causing her agony and denying her a peaceful death.
NHS in England
Jul 2025
P-001283 — Birmingham and Solihull Clinical Commissioning Group
Mr A complained the Care Home failed to ensure adequate nutritional intake and missed opportunities for end-of-life medication for his mother. He also complained the CCG delayed her Continuing Healthcare (CHC) assessment.
NHS in England
Jan 2022
P-001447 — A care home in the Warrington area
Mrs X complained that staff at her father's care home lost his dentures, causing her distress, anger, and upset.
NHS in England
Jun 2022
P-001725 — Kent Community Health NHS Foundation Trust
Community nurses failed to properly monitor and care for Mrs Y's pressure ulcer, which Mrs D believes contributed to her mother's health decline and death.
NHS in England
Not Upheld
Jan 2023
P-002447 — A care home in the Birmingham area
Mr O complained his mother suffered several unwitnessed falls at a care home in 2021 due to insufficient monitoring, leading to injuries and distress.
NHS in England
Feb 2024
P-003028 — A practice in the Leeds area
Mr & Mrs R complained the care home provided inadequate end-of-life care and the Practice failed to address their concerns for their mother in 2019, potentially shortening her life.
NHS in England
Oct 2024
P-001900 — The Chaseley Trust
Mrs R complained staff administered too much Fucidin cream, failed to administer eye drops correctly, and did not notify her about a hospital appointment.
NHS in England
Mar 2023
P-002962 — Black Country Integrated Care Board
Mrs L complained about the care her husband received from a care home and the ICB before his death, specifically regarding conflicting information and an unexplained death.
NHS in England
Sep 2024
P-004434 — An independent provider in the East Hampshire area
Complaint alleged a trust discharged a mother when she was unfit and without end-of-life medication, and a nursing home failed to provide medication, use a BIPAP machine, or correctly hoist her.
NHS in England
Partly Upheld
Nov 2025
P-002306 — The Dudley Group NHS Foundation Trust
Mrs D complained her mother developed fatal pressure sores due to neglect, citing poor communication and frequent ward changes as contributing factors to her deteriorating health.
NHS in England
Nov 2023
P-002345 — University Hospitals Dorset NHS Foundation Trust
Mrs T complained her mother developed preventable pressure sores due to negligent care provided by the Trust.
NHS in England
Dec 2023
P-003401 — Manchester University NHS Foundation Trust
Ms C complained about poor pressure ulcer management, unused barrier cream, and poor hygiene, which she believes worsened her mother's wounds and contributed to sepsis and death.
NHS in England
Partly Upheld
Mar 2025
LGO / SPSO decisions(199)
22-000-526a — Akari Care (22 000 526a)
Summary: Mr B complained about the actions of a Care Provider because he says his late mother’s rings went missing in one of its nursing homes. He also said the Council did not do enough to investigate the matter. We did not find fault by the Council. The Care Provider …
LGO (Local Government & …
Health
Upheld
Oct 2022
NIPSO-16874 — Belfast Health and Social Care Trust
The Ombudsman has found that the Belfast Health and Social Care Trust made a concerted attempt to resolve a complainant’s concerns about the care and treatment provided to her father while he was the resident of a Belfast nursing home.
NIPSO (NI Public Service…
Health & Social Care
Mar 2018
PSOW-202106081 — A Care Home
Mrs A complained about the actions of Aneurin Bevan University Health Board (“the Health Board”) in relation to the care provided to her late mother, Mrs B. Specifically, Mrs A complained that Mrs B’s needs (as set out in her Care Plan) were not met, there was a failure to …
PSOW (Public Services Om…
Upheld
Oct 2023
21-002-727 — Salford City Council
Summary: Ms X complained the Fountains Nursing Home failed to provide adequate care to her father in the hours prior to his death and that the Council’s safeguarding investigation was flawed. The Council has already identified fault, mainly around communication with the family and the Nursing Home’s recording of events. …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-007-659 — Cumbria County Council
Summary: Mrs X complained about the level of care provided to her mother, Ms Y, in the last few days of her life by the care home. She also complained about the clearing of Ms Y’s room and the way her belongings were handled. There were failings in the care …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-018-066 — Saima Raja AKA Braemar Care Centre
Summary: We will not investigate this complaint about the Care Provider refusing to issue a refund. This is because the Care Provider has now issued the refund. This remedies the claimed injustice and an investigation could not achieve anything more.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-018-569c — The Coach House Residential Home (21 018 569c)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-018-569a — Norfolk & Suffolk NHS Foundation Trust (21 018 …
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or …
LGO (Local Government & …
Health
Not Upheld
Oct 2022
21-017-330a — Rutland House (21 017 330a)
Summary: Mrs B complained to the Ombudsmen that a Care Home provided inadequate care to her son. She complained this led to significant, life-changing consequences for him. We decided not to investigate Mrs B’s complaint. This is because it is unlikely we would reach meaningful, evidence-based findings that the Care …
LGO (Local Government & …
Health
Nov 2022
23-013-793a — High Peak Lodge (23 013 793a)
Summary: We uphold Mrs Y’s complaint about her grandmother’s care. We found fault with Mrs X’s continence care and some aspects of her end of life care. We also found fault with the Care Home’s record keeping and the Council’s communication. As a result, Mrs X did not always receive …
LGO (Local Government & …
Health
Upheld
Aug 2024
24-007-003 — Oldham Metropolitan Borough Council
Summary: We will not investigate this complaint about the way the Council arranged access for Mr B to remove his personal belongings from his former home when his tenancy ended. We will not investigate Mr B’s complaint about the bed in his care home and having access to his mobile …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2025
24-006-556 — Ideal Care Homes Ltd
Summary: Ms A and her sister Ms B complain that the care provider gave notice on their late father’s placement without due reason and they had to find another placement at short notice for their elderly father who has dementia. The care provider failed to meet Mr X’s needs and …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2025
24-018-961 — Sefton Metropolitan Borough Council
Summary: Mrs B complained about the standard of care her mother, Mrs X, received when the Council organised a placement at Lakeside View Care Home. We uphold the complaint, having identified several areas of fault with the care provided to Mrs X, and inaccurate care records. There was also fault …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
24-019-982 — Sheffield City Council
Summary: There was significant fault on the part of the Council’s commissioned care provider which caused considerable injustice to the late Mr X. The Council has acknowledged the failings by the care provider and overseen service improvements and will now make a payment to acknowledge the distress and anxiety caused …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
25-002-861 — Borough Care Ltd
Summary: The Care Provider was at fault for not maintaining Y’s personal hygiene and for delaying its response to Mr X’s concerns about the matter. The Care Provider further failed to keep adequate records about the issue. It also failed to record how it assessed Y’s capacity when obtaining consent …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
24-021-792 — Cambridgeshire County Council
Summary: The Council’s commissioned care provider failed to provide a good standard of care for the late Mrs X, failed to keep proper records in accordance with the regulations and did not provide her nutrition in accordance with the hospital discharge instructions. The Council agrees to recognise the considerable distress …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
NIPSO-21518 — Northern Health and Social Care Trust
We found that the Northern Health and Social Care Trust carried out a safeguarding investigation broadly in line with its procedures, but were critical that the investigation did not find out how the resident sustained bruising during her time in the home.
NIPSO (NI Public Service…
Health & Social Care
Aug 2021
NIPSO-20903 — Western Health and Social Care Trust
We asked the Western Health and Social Care Trust to use the newly appointed Learning Disability Acute Liaison Nurse to ensure that appropriate training is provided to staff who care for patients with disabilities. We also recommended it develop an online information resource for staff to help them care for …
NIPSO (NI Public Service…
Health
Aug 2021
25-025-498 — HC-One Limited
Summary: We will not investigate Mr X’s complaint about the Care Home failing to correctly administer medication to his father, Mr Y. This is because we would not be able to add to the Care Provider’s investigation and we would not be able to achieve the outcome Mr X wants.
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
24-022-122 — Welford Healthcare MC Ltd
Summary: Mrs Y complains about several aspects of the care delivered to her father, Mr W, whilst resident in Isle Court Nursing Home. We find the home did not properly document the change from respite to permanent care and did not record times when it said Mr W refused personal …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
24-018-019 — Barchester Healthcare Homes Limited
Summary: There was fault on the part of the care provider which led to suffering and distress for Mr X and distress for Mrs X. The care provider acknowledges fault in its record keeping and offers a goodwill payment. It should make a more significant payment to reflect the injustice …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2026
21-002-153 — Leicestershire County Council
Summary: Mrs Y complains about the failure of a care provider to ensure a sore on her mother’s leg was appropriately cleaned, dressed and treated. We find fault because there is no evidence to show the care provider properly assessed the sore or sought medical help. This fault creates distress …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-001-913 — B & M Care/Colleycare Ltd
Summary: Mr C complains about the way the care provider dealt with notice period charges and the return of belongings after his mother left the care home. Mr C says the care provider did not try to mitigate its financial loss when his mother left the home and should waive …
LGO (Local Government & …
Adult Care Services
Not Upheld
Feb 2022
21-004-180 — North Tyneside Metropolitan Borough Council
Summary: There was fault by the Council in failing to audit Ms Y’s direct payment or carry out yearly financial assessments. This caused Ms Y and her family avoidable confusion. The Council will apologise, write off an overspend, reclaim an overpayment, reduce the outstanding client contribution and take action to …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-012-668a — Royal Wolverhampton Hospital NHS Trust (20 012 668a)
Summary: The Ombudsmen find a Nursing Home, Hospital Trust and Ambulance Trust responded appropriately when a Nursing Home resident became unwell in March 2020. Based on the evidence seen to date, professionals completed appropriate assessments and acted in line with guidance in place at that time. There was fault in …
LGO (Local Government & …
Health
Not Upheld
Mar 2022
21-005-089 — Country Court Care Homes 3 OpCo Limited
Summary: Mrs X complained on behalf of Mrs Y, about the care she received at Tallington Care Home (the Care Provider). She says Mrs Y was put at risk and when family raised concerns, staff were aggressive. We found the Care Provider did cause injustice to Mrs Y and Mrs …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-010-548 — Willow Tower Opco 1 Limited
Summary: Mr U complains that despite his warnings, the care provider left his wife unsupervised near to another resident. This led to his wife falling and breaking her leg. He says the care provider should pay for the cost of adaptations to their home. We uphold the complaint. But we …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-011-877 — Longfield (Care Homes) Limited
Summary: Ms Z complained about an inaccurate invoice for outstanding care fees. Based on the information available, I intend to find fault in the actions of the Care Provider for failing to identify and prevent an accumulation of arrears. This fault has caused an injustice to Ms X, and we …
LGO (Local Government & …
Adult Care Services
Not Upheld
Aug 2022
22-005-146 — Northumberland County Council
Summary: We will not investigate this complaint about a care home. That is because we could not add to the Care Providers previous investigation.
LGO (Local Government & …
Adult Care Services
Aug 2022
21-004-973 — Barchester Healthcare Homes Limited
Summary: Mrs D complains about the standard of care and support her father (Mr H) received while in residential care. Among other things, Mrs D says the Care Provider failed to meet Mr H’s health and care needs and provided him medication he was not prescribed. We found some fault …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-017-704 — Solent Cliffs Nursing Home Limited
Summary: Mr C complained about the care his (late) mother received at the care home she lived. He said this resulted in distress to him and his mother. We found there was a delay by the care home in ensuring Ms X had heating in her room, and the staff …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-013-244 — The Franklyn Group Limited
Summary: Mrs X complained about the care her mother, Ms Y, received at the Care Provider’s Gatehouse Care Home in Harrogate, and its decision to end her contract. The Care Provider was at fault, and this caused Ms Y a financial loss and caused her family avoidable confusion and distress. …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-011-711d — CSH Surrey (21 011 711d)
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track …
LGO (Local Government & …
Health
Upheld
Sep 2022
21-011-711c — Woking and Sam Beare Hospice and Wellbeing Care …
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track …
LGO (Local Government & …
Health
Not Upheld
Sep 2022
21-014-368 — Avery Homes (Nelson) Limited
Summary: Mr X’s condition deteriorated while he was at the home for respite care. There is some evidence this was due to poor care and treatment on the part of the care provider. There was also an unexplained pressure sore on discharge which the care provider did not notice. The …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
23-011-659 — Barchester Healthcare Homes Limited
Summary: Mrs X complains, on behalf of her father, Mr Y, Barchester Healthcare Homes Limited mishandled the pre-admission process and failed to ask relevant questions before her father moved into in the home. She says the Care Provider failed to engage with her or social services to complete a re-assessment. …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2024
23-004-006 — Macc Care (Boldmere) Ltd
Summary: Mrs X complained the care provider failed to provide adequate care and support to her late mother Mrs Y. The care provider was at fault for poor record keeping relating to Mrs Y’s meals and dental care, for failing to follow up attempts to take a urine test and …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
23-010-449 — Avery Homes (Cannock) Limited
Summary: Ms X complained about issues with the service and care provided by Avery Homes Limited. We find Avery Homes Limited at fault for providing insufficient care which caused distress to Ms X and her family. Avery Homes Limited has apologised to Ms X, refunded care homes fees and made …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-020-716 — Bupa Care Homes (AKW) Limited
Summary: We will not investigate this complaint about adult social care in a residential care home. The Care Provider has accepted failings in communication and record keeping, has apologised, and has spoken with staff to improve service. It is unlikely an Ombudsman investigation would add to this or lead to …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-013-390 — City of Bradford Metropolitan District Council
Summary: Mr X complained Norwood House Care Home breached the terms of their agreement by increasing his mother, Ms Y’s, top up fee several times without proper notice or consultation and without notifying the Council. We found there was fault causing injustice when the Care Home failed to follow the …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-015-722 — Staffordshire County Council
Summary: A care home, owned by the Council, failed to take appropriate action to manage the falls risk for Mrs Y, despite her vulnerability.
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2024
24-001-036 — Burlington Care (Yorkshire) Limited
Summary: We will not investigate this complaint about Mrs D’s care provider charging for care. This is because the Care Provider has remedied the injustice caused by fault and we are satisfied with this remedy.
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2024
24-000-547 — Brighton & Hove City Council
Summary: We will not investigate this complaint about lost items within a care home. This is because it is unlikely we could add to the care provider’s investigation which could not identify how and when the items went missing. It would be more suitable for the police or insurance company …
LGO (Local Government & …
Adult Care Services
Jun 2024
24-005-088 — Hampshire County Council
Summary: We will not investigate this late complaint about care provided in a residential home. There is not a good reason for the delay in complaining and we could not carry out a meaningful investigation given the time that has passed since events.
LGO (Local Government & …
Adult Care Services
Aug 2024
23-016-681 — New Care Nottingham (Opco) Limited
Summary: Ms G complained about the care and support provided to her late father, Mr D by the Care Provider. We found fault with the Care Provider’s record keeping and the accuracy of information it recorded in Mr D’s care records. Some of the care Mr D received fell below …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2024
24-017-338 — North Yorkshire Council
Summary: We will not investigate Mrs X’s complaint the Council misled her sister into thinking she would be moving to a care home. This is because an investigation would not lead to any worthwhile outcomes. In addition, we are not likely to find fault.
LGO (Local Government & …
Adult Care Services
Mar 2025
24-015-525 — Avery Homes Grove Park Limited
Summary: We will not investigate this complaint about the standards of care and level of service the complainant received while in residential care. This is because there is insufficient evidence of any actions by the Care Provider having causing the complainant to suffer a significant and personal injustice.
LGO (Local Government & …
Adult Care Services
Mar 2025
23-020-500 — Heathfield Care Homes Limited
Summary: Mrs B complains about the care home’s delay in calling an ambulance for her mother and says her mother suffered dehydration and pressure sores because of the care home’s failures in care. We have not found fault in the way the care home decided to call an ambulance or …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2025
24-012-697 — Revitalise Respite Holidays
Summary: Ms X complained about the care Revitalise Respite Holidays (the Care Provider) provided to her daughter, Ms Y. Ms X is unhappy about how care workers treated Ms Y’s tightly coiled hair when it was in braids. The Care Provider was at fault for poor record keeping, a flawed …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2025
24-020-592 — Barchester Healthcare Homes Limited
Summary: We will not investigate this complaint about adult social care during a short respite break at a care home. The Care Provider accepted some fault, apologised, offered £200, and gave staff training to improve future service. We are satisfied with its actions in response to the complaint, and it …
LGO (Local Government & …
Adult Care Services
Upheld
May 2025
Domestic Homicide Reviews(9)
Barnsley — recommendation A9
Audit adherence to the above.
South West Yorkshire Partnership (NHS) Foundation …
Stockport — recommendation 21
Pennine Care NHS Foundation Trust : change incident reporting and management policy to implement structures and processes as described in NHS Serious Incident Framework March 2015
Pennine Care NHS Foundation Trust
Pennine Care NHS Foundation …
Northampton — recommendation 4
The Department to devise and implement an Audit Framework that seeks to ensure that each tier of staff including management carry out frequent audits including peer audits.
Northampton County Council
Southampton City Council
Gloucestershire — recommendation 17.3.2
The home has changed their protocols so that all visitors have to ring the bell and sign the visitor’s book, which now includes their relationship with the resident they are visiting. This will be kept under review.
Health Care Company
Gloucestershire — recommendation 17.3.1
The group will introduce a policy that when a resident presses their assistance bell the responding member of staff will check with them personally other than accepting the word of a visitor. This will be included in all staff training.
Health Care Company
Gloucestershire — recommendation 17.2.1
Care and nursing home providers should introduce a procedural policy that when a resident presses their assistance bell the responding member of staff should check their needs with them personally, rather than accepting the word of a visitor. Management teams should ensure that all staff are aware of this policy …
Care and nursing home providers
West Lancashire — recommendation 33
Completion of an audit by West Lancashire Home Treatment Team that focusses on the quality of risk assessments, with necessary further actions taken should there be evidence of further concerns in this regard
Lancashire and South Cumbria NHS Foundation …
Lancashire and South Cumbria …
Tendring — recommendation 25
A three monthly audit of patient records should be developed and undertaken over a period of twelve months to monitor compliance with the holistic assessment template. Findings of the audit should be used to identify further quality improvement opportunities.
Anglia Community Enterprises
Anglian Community Enterprise
Tendring — recommendation 24
A three monthly audit of patient records should be developed and undertaken over a period of twelve months to monitor compliance with the use of and effectiveness of the safeguarding adults’ template. Findings of the audit should be used to identify further quality improvement opportunities.
Anglia Community Enterprises
Anglian Community Enterprise