Care home infection control
Failure to safely follow infection prevention and control (IPC) practices in care homes, risking outbreaks and resident health.
Source spread
Where this theme appears
This theme appears across 14 independent accountability sources, so the source mix matters as much as the headline total.
24 inquiry recs
26 PFD reports
30 committee recs
1 HSSIB rec
262 CQC actions
1 PPO rec
30 IMB recs
2 patient safety alerts
5 detention investigation recs
30 PHSO decisions
73 LGO/SPSO decisions
1 CJINI report
4 CQC enforcement actions
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(24)
R66 — Healthcare environment maintenance
Recommendation: Health Boards should ensure that the healthcare environment does not compromise effective infection prevention and control, and that poor maintenance practices, such as the acceptance of non-intact surfaces that could compromise effective infection prevention and control practice, are not tolerated.
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
R65 — Isolation for infectious diarrhoea
Recommendation: Health Boards should ensure that appropriate steps are taken to isolate patients with potentially infectious diarrhoea.
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
R63 — Effective CDI patient isolation
Recommendation: Health Boards should ensure that there is effective isolation of any patient who is suspected of suffering from CDI, and that failure to isolate is reported to senior management.
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
R60 — Cleanliness Champions implementation
Recommendation: Health Boards should ensure that programmes designed to improve staff knowledge of good infection prevention and control practice, such as the Cleanliness Champions Programme, are implemented without undue delay. Staff should be given protected time by managers to complete such …
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
R67 — Link Nurse training
Recommendation: Health Boards should ensure that, where a local Link Nurse system is in place as part of the infection prevention and control system, the Link Nurses have specific training for that role. The role should be written into job descriptions …
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
R64 — Cohorting only exceptional
Recommendation: Health Boards should ensure that cohorting is not used as a substitute for single room isolation and is only resorted to in exceptional circumstances and under strict conditions of dedicated nursing, with infected patients nursed in cohort bays with en-suite …
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
R62 — Senior manager clinical visits
Recommendation: Health Boards should ensure that senior managers accompanied by infection prevention and control staff visit clinical areas at least weekly to verify that proper attention is being paid to infection prevention and control.
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
R61 — Unannounced inspections with lay representation
Recommendation: Health Boards should ensure that unannounced inspections of clinical areas are conducted by senior infection prevention and control staff accompanied by lay representation to examine infection prevention and control arrangements, including policy implementation and cleanliness.
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
R59 — Priority attendance at IPC meetings
Recommendation: Health Boards should ensure that attendance by members of committees in the infection prevention and control structure is treated as a priority. Non-attendance should only be justified by illness or leave or if there is a risk of compromise to …
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
R52 — IPC policy adherence audits
Recommendation: Health Boards should ensure that adherence to infection prevention and control policies, for example the C. difficile and Loose Stool Policies, is audited at least annually, and that serious non-adherence is reported to the Board.
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
R50 — 24/7 IPC cover
Recommendation: Health Boards should ensure that there is 24-hour cover for infection prevention and control seven days a week, and that contingency plans for leave and sickness absence are in place.
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
R43 — IPC staff regular training
Recommendation: Health Boards should ensure that Infection Control Nurses and Infection Control Doctors have regular training in infection prevention and control, of which a record should be kept.
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
R42 — Mandatory IPC training
Recommendation: Health Boards should ensure that all those working in a healthcare setting have mandatory infection prevention and control training that includes CDI on appointment and regularly thereafter. Staff records should be audited to ensure that such training has taken place.
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
R9 — IPC clinical governance meetings
Recommendation: Health Boards should ensure that infection prevention and control is explicitly considered at all clinical governance committee meetings from local level to Board level.
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
R3 — IPC policy review
Recommendation: Health Boards should ensure that infection prevention and control policies are reviewed promptly in response to any new policies or guidance issued by or on behalf of the Scottish Government, and in any event at specific review dates no more …
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
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
R53 — Surveillance systems fit for purpose
Recommendation: Health Boards should ensure that surveillance systems are fit for purpose, are simple to use and monitor, and provide information on potential outbreaks in real time.
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
R17 — Ward admission responsibility
Recommendation: Health Boards should ensure that where there is risk of cross infection, the nurse in charge of a ward has ultimate responsibility for admission of patients to the ward or bay. Any such decision should be based on a full …
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
R12 — CDI infection control advice
Recommendation: Health Boards should ensure that when a patient has CDI patients and relatives are given clear and proper advice on the necessary infection control precautions, particularly hand washing and laundry. Should it be necessary to request relatives to take soiled …
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
F240 — Hygiene
Recommendation: All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged to remind anyone, however senior, of these.
Gov response: Accepted. In its initial response to The Inquiry, Patients First and Foremost, the Government committed to draw up a new set of fundamental standards of care that will sit within the legal requirements that providers …
Accepted
R20 — Stool records for CDI patients
Recommendation: Health Boards should ensure that where a patient has, or is suspected of having, C. difficile diarrhoea a proper record of the patient’s stools is kept. Health Boards should ensure that there is an appropriate form of charting of stools …
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
R16 — CDI outbreak reporting
Recommendation: Health Boards should ensure that the nurse in charge of each ward reports suspected outbreaks of CDI (as defined in local guidance) to the Infection Control Team.
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
R2 — HAI implementation strategy
Recommendation: Scottish Government should ensure that policies and guidance on healthcare associated infection are accompanied by an implementation strategy and that implementation is monitored.
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
SHI-11 — Training for IPC professionals engineers and clinicians
Recommendation: I would recommend that IPC professionals should receive some basic training on the recommendations made by the NHS's own guidance for engineering systems, insofar as they are made in the interests of patient safety and care, before they are recruited …
Gov response: On 13 March 2025, I made a statement in parliament, addressing the Interim Report and its recommendations. I accepted all recommendations and committed to provide a future update on progress around the implementation of those …
Accepted
Prevention of Future Deaths reports(26)
Wilhelmina Isobel Newton
Concerns: The coroner noted the absence of a clear written plan or guidance for staff regarding responses to head injuries in elderly residents, particularly those on anti-clotting medication, a gap that may affect other council-operated homes.
Response (Cumbria County Council): • Cumbria County Council has reviewed the issue of protocols for head injuries in elderly residents, particularly those on anti-clotting medication. • New guidance has been developed by Cumbria County … (AI summary)
Responded
Barbara Cooke
Concerns: Inadequate staffing at Waxham House impacted timely personal care and dignity, alongside insufficient protocols for chasing district nurses. St Mary's Hospital lacked systems for recording and reporting safeguarding alerts for inpatients.
Overdue
Martin Dean
Concerns: The coroner noted visitors to the Critical Care Ward were not consistently washing their hands, identifying a lack of measures to ensure this essential infection control precaution was followed.
Overdue
Margaret Clarke
Concerns: The coroner noted an absence of guidance for the effective cleaning of fixed shower heads, which are increasingly used in private and public leisure facilities.
Response (Health and Safety Executive): • The Health and Safety Executive stated that shower heads are designed, manufactured, and supplied under the General Product Safety Regulations 2005. • The Health and Safety Executive noted it … (AI summary)
Response (Doncaster Borough Council): • Doncaster Borough Council stated that no specific regulations apply to showerheads under the Consumer Protection Act 1987. • The council indicated that fixed shower heads are likely intended for … (AI summary)
Responded
Eliza Simpson
Concerns: The care home had no system for reassessing residents when Deprivation of Liberty Safeguarding orders expired, which could lead to a lack of legal authority and insufficient observation. The absence of CCTV also hampered the subsequent police investigation.
Overdue
May Hall
Concerns: The coroner noted staff at Bourne House were unaware of policies for reporting falls and contacting emergency services, raising concerns about the lack of clear, regularly reviewed training on addressing falls.
Overdue
Thomas Nicholls
Concerns: The coroner identified a lack of care staff training regarding the mobility, handling, and care of residents on PEG feed regimes. There was also a failure to report an incident of projectile vomiting during PEG feeding to the care home manager.
Overdue
Elsie Brown
Concerns: The coroner noted the absence of falls and bed rail risk assessments for Mrs Brown, an incomplete and unreviewed care plan, and a lack of clarity regarding assessment responsibilities. Concerns were also raised about insufficient night staffing levels, informal handovers, and inadequate auditing processes.
Response (Elsie Brown): • The company appointed an independent consultant in December 2015 to investigate why corporate documentation, including falls and bed rail assessments, was not used in Mrs Brown's care plan. • … (AI summary)
Responded
Alwyn Head
Concerns: The coroner noted concerns regarding the patient's MRSA history not being established pre-surgery, and a lack of prophylactic medication. There was no post-operative wound care plan, insufficient surgical wound inspection, and inadequate documentation of wound status.
Response (A head): • New admission/transfer assessment documentation for patient infection status was introduced, with staff training and daily monitoring by the infection control team. • Orthopaedic antimicrobial guidelines were updated, and the … (AI summary)
Responded
Ronald Farrington
Concerns: The coroner noted Nuffield Care Centre's failure to follow tissue viability nurse advice, maintain accurate records, and refer a patient to a GP for infection. Concerns also arose regarding insufficient tissue viability nurse staffing, inadequate CQC evidence collection, and lack of family involvement in reviews.
Response: • Surrey County Council Adult Social Care services completed an adult safeguarding enquiry with Nuffield Care and the family. • Systems were improved to identify and reduce the number of … (AI summary)
Response (Ronald Farrington): • The care centre implemented a new auditing system for wound care, involving weekly manager audits and monthly general manager and senior management team reviews. • A formal wound assessment … (AI summary)
Overdue
John Edwards
Concerns: The care home placement was inappropriate for the resident's complex needs, with inadequate falls and pressure sore prevention policies. Staff did not recognise deterioration, seek timely medical assistance, or properly manage medication and care records.
Response (Response Southwinds Limited): • The organisation stated it closed in December 2017. • The organisation indicated that in this circumstance, no action could be taken. (AI summary)
Overdue
Andrew Clegg
Concerns: Architects designing care homes and healthcare premises rarely account for water safety in design, particularly concerning legionella prevention through pipework layout. Additionally, CQC inspectors lack training to identify legionella infection risks during their water safety inspections.
Response: • The Care Quality Commission suggested the development of a tailored training course in Legionella awareness for all inspectors. • The Care Quality Commission is agreeing an updated Memorandum of … (AI summary)
Overdue
Irene Collins
Concerns: Concerns were raised about residents having unrestricted access to clinical examination gloves and their disposal in easily accessible bins in care settings. Authoritative guidance on the storage and disposal of such gloves is recommended.
Overdue
Joan Sanderson
Concerns: The coroner noted the absence of a routine MRSA swab on hospital admission for certain patient groups, which delayed the early identification of infection. This practice could impact outcomes in cases requiring emergency surgery with postoperative infection.
Response (GM Health and Social Care Partnership and Healthcare Safety Investigation Branchwillbe): • The Greater Manchester Health and Social Care Partnership (GMHSCP) reported that the MRSA Policy was updated in February 2019 to align with national screening guidance for specific patient admissions. … (AI summary)
Overdue
Anthony Slack
Concerns: The coroner noted limited documentation and observations at the care home, an unclear COVID-19 origin due to no admission risk assessment, and staff confusion over PPE guidance. Ambulance delays also impacted the transport of vulnerable patients to acute settings.
Response (NHS England and NHS Digital): • North West Ambulance Service (NWAS) established cleaning teams to assist ambulance crews with additional cleaning following patient handovers. • The cleaning service was initially rolled out to eight Emergency … (AI summary)
Response (UK Health Security Agency): • The UK Health Security Agency (formerly Public Health England) established a national team to lead the organisational response to COVID-19 in adult social care settings, coordinating with partners and … (AI summary)
Response (CQC): • The care home implemented improved post-falls management systems, including new observation protocols, monitoring equipment, and staff training on daily record keeping. • The care home confirmed adherence to government … (AI summary)
Response (Greater Manchester Health and Social Care Partnership): • The care home accepted documentation awareness training and updated its Covid-19 admission procedures to require a negative test. • NWAS established cleaning teams at Emergency Departments, including Tameside Hospital, … (AI summary)
Response (Vicarage Care Home): • The care home completed documentation training for all staff and updated its recording policy and proformas. • It implemented regular COVID-19 and infection control training, reviewed its admission policy, … (AI summary)
Responded
Alvin Black
Overdue
Joyce Dennis
Concerns: The care home lacked continuous oversight, sufficient notes, and a process for recording family concerns. Staff training was inadequate regarding subtle signs of illness and sepsis in the elderly, leading to a failure to recognise and escalate health deterioration.
Overdue
Lilian Behrendt
Concerns: The coroner noted inadequate record-keeping for a resident's deteriorating condition, including missing observation results and unclear advanced care planning. There were also concerns about insufficient mobile recording devices and a lack of clear ownership and accountability for resident care.
Response (Kingsley Healthcare): • The company removed emotionally-charged words from its electronic care management system (PCS), requiring staff to manually describe service user presentation, and reduced reliance on visual icons. • All staff … (AI summary)
Overdue
Karen Starling and Anne Martinez
Concerns: The coroner highlights an incomplete understanding of M abscessus in hospital water systems. Health Technical Memorandum 04-01 lacks specific guidance for identifying, controlling, or testing for M abscessus, especially for immunosuppressed patients and new hospitals.
Response (NHS England): • NHS England provided oversight and support to Royal Papworth Hospital, including establishing incident management meetings and facilitating collaboration with UKHSA. • NHS England's National Principal Engineer conducted a site … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care acknowledged receipt of the letter regarding the deaths of Karen Starling and Anne Martinez. • The Department stated that Health Technical Memorandums … (AI summary)
Responded
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 (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)
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)
Responded
Terence Hines
Concerns: The coroner identified the absence of a required "Red clean" for a room previously occupied by a patient with MRSA before Mr. Hines' transfer, alongside the omission of routine MRSA screenings that should have occurred during his prolonged inpatient stay and prior to surgery.
Response (Worcestershire Acute Hospitals): • The Trust updated its Red, Amber, Green (RAG) clean policy and guidance, including new posters and an updated Record of Terminal Cleans, to clarify requirements for MRSA patients. • … (AI summary)
Responded
Joan Blaber
Concerns: The coroner identified ongoing non-compliance with Control of Substances Hazardous to Health Regulations (COSHH), alongside inadequate training and monitoring for staff handling hazardous substances. Concerns were also raised about confusion in staff roles, failures in communicating important practices, and a lack of systems for reporting and learning from suboptimal events.
Response (Brighton and Sussex University Hospitals): • The Trust revised COSHH folders, updated COSHH training, and clarified the distinct roles of Housekeepers and Catering Assistants. • It implemented new management structures for these roles, introduced clear … (AI summary)
Responded
Patricia Lines
Concerns: The coroner raised concerns about the national guidance for skin cleaning prior to injections, which suggests cleaning is not necessary if skin is clean. The report noted this advice, based on dated evidence, contrasts with the bacterial reduction achieved by alcohol wipes.
Response (NHS England): • NHS England stated it would review the contents of UKHSA’s response regarding 'The Green Book' once received. (AI summary)
Response (UK HSA): • UKHSA stated that its 'Green Book' guidance advises that only visibly dirty skin needs to be washed with soap and water before vaccinations, and disinfection is not necessary. • … (AI summary)
Response (Browney House Surgery): • The practice discussed the report with clinicians and management staff. • The case will be used as a learning exercise in clinical staff appraisals. • Clinical staff will enroll … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care reviewed the concerns outlined in the report. • The Department of Health and Social Care determined that UK Health Security Agency (UKHSA) … (AI summary)
Responded
Walter Horton
Concerns: Poor record keeping was identified in key areas such as falls, wound management, and discharge handovers. There was also a lack of understanding or adherence to aseptic techniques and cleanliness during wound management, increasing infection risk.
Response (Doncaster Bassetlaw NHS Foundation Trust): • The Trust confirmed a safeguarding referral was made on admission. • The Trust stated a discharge letter was sent to the care home and electronically to the GP. • … (AI summary)
Response (Doncaster and Bassetlaw Teaching Hospitals NHS FT): • The Trust stated that falls prevention is a Trust-wide safety priority, with an action plan monitored through established governance processes. • The Trust maintains a comprehensive skin integrity improvement … (AI summary)
Responded
Barbara Wingate
Concerns: The coroner noted frequent overcrowding in the resuscitation department, stemming from delayed patient discharges due to insufficient timely community care packages and alternative placements from social and community healthcare providers.
Response (Kent County Council): • Kent County Council conducted a recruitment campaign and implemented efficiencies in referral processes for the Kent Enablement at Home team. • The council improved referral processes for the short-term … (AI summary)
Response (Kent and Medway ICB): • The Medway Care Transfer Hub was established as a single coordination and escalation point for patients requiring new residential or nursing placements. • A structured daily approach was implemented … (AI summary)
Response (Medway Council): • The Council recommissioned the Integrated Care and Reablement Service to increase community health bed capacity. • The Council introduced 24-hour care at home services to support individuals with high … (AI summary)
Response (Kent County Council): • Kent County Council implemented a recruitment campaign and created efficiencies in referral processes, reducing the average referral to discharge time for home-based services to 1.8 days. • Improvements to … (AI summary)
Response (Kent and Medway Integrated Care Board): • The Medway Care Transfer Hub was established to coordinate and escalate support for patients requiring new residential or nursing placements. • A structured daily approach was implemented to maximise … (AI summary)
Responded
Rhoda Freedman
Response (Swiftclean): Swiftclean acknowledges that their post-incident Legionella Risk Assessment (LRA) for Wensley House was not robust. They are implementing an action plan to address identified non-conformances, including re-conducting the LRA, updating … (AI summary)
Response (AquaCert): AquaCert stated it has no control over Wensley House's water systems or staff training. However, it has amended its pre/post flush sample collection document and plans multiple changes to its … (AI summary)
Response (Wensley House Residential Care Home): The Home engaged Swiftclean for water management, removed dead legs, replaced taps/showerheads, insulated pipes, and installed a water dosing system. All staff completed Legionella awareness training, key personnel completed specialist … (AI summary)
Responded
Select committee recommendations(30)
#21 —
Recommendation: Local authorities play a significant role in all parts of the UK government’s response to COVID-19. They have key obligations such as to deliver social care, other parts of the emergency response and support for individuals and businesses. Central government …
Response status not verified
#16 —
Recommendation: The Cabinet Office acknowledged that it was taken by surprise by the need for a massive quantity of protective equipment, and by the difficulty of sourcing it from reliable UK-based suppliers.36 It said that a particular challenge was supplying PPE …
Response status not verified
#5 —
Recommendation: There were fundamental flaws in the government’s central procurement and local distribution of vital goods and equipment. We recognise that the government was faced with a massive challenge to procure a huge quantity of personal protective equipment (PPE) for 58,000 …
Response status not verified
#9 —
Recommendation: We are pleased to hear that more than 98% of the prison estate now has cohorting in place. This appears to have been an effective strategy for containing the spread of the virus and protect the lives of staff and …
Gov response: In March we introduced cohorting strategies, including the ‘compartmentalisation strategy’ across the estate, to isolate the sick, shield the vulnerable and quarantine new arrivals, based on advice from PHE. We are pleased to report that …
Position Not Stated
#22 —
Recommendation: Testing for NHS workers (with symptoms) only began from 27 March, with eligibility extended to social care workers (with symptoms) from 15 April, after the pandemic had passed its first peak. In the period up to 15th April up to …
Response attribution not verified
#11 —
Recommendation: We remained concerned that the Department had continued its policy of discharging people untested into care homes even once it was clear there was an emerging problem.26 The number of first-time outbreaks in individual care homes peaked at 1,009 in …
Response attribution not verified
#9 —
Recommendation: On 17 March the NHS told trusts to discharge urgently all medically fit hospital patients with COVID-19 to maximise inpatient and critical care capacity. On 2 April, the Department told care homes that they needed to make their full capacity …
Response attribution not verified
#2 —
Recommendation: Discharging patients from hospital into social care without first testing them for COVID-19 was an appalling error. Shockingly, Government policy up to and including 15 April was to not test all patients discharged from hospital for COVID-19. In the period …
Response attribution not verified
#27 —
Recommendation: When infections take hold in prisons they can be very serious, so we were relieved to hear that the scale of the pandemic in prisons had not been as bad as was predicted at the outset. The Ministry and HMPPS …
Response attribution not verified
#26 —
Recommendation: By 19 June 2020, some 500 prisoners and 10 children in custody had tested positive for COVID-19. A further 992 staff within HMPPS had tested positive for the virus. Up to 26 June 2020, 44 people categorised as ‘HMPPS service …
Response attribution not verified
#51 —
Recommendation: The Government should review the provision of infection prevention and control measures, including infection prevention and control nurses, to social care and ensure that social care providers, particularly care homes, are able to conduct regular pandemic preparedness drills. The Government …
Response attribution not verified
#46 —
Recommendation: Staff shortages, the lack of testing, difficulties in obtaining PPE and the design of care settings to enable communal living hampered isolation and infection control and the ability to keep covid at bay. Social care staff in care homes and …
Response attribution not verified
#51 —
Recommendation: The Government should review the provision of infection prevention and control measures, including infection prevention and control nurses, to social care and ensure that social care providers, particularly care homes, are able to conduct regular pandemic preparedness drills. The Government …
Response attribution not verified
#28 — NHS staff inconsistently adhere to basic infection prevention and control procedures.
Recommendation: We asked about issues with infection prevention and whether some of the basics were not being upheld as much as they should. DHSC said that we should not underestimate how much of the battle against AMR “is really basic things”, …
Response attribution not verified
#27 — Hospital-acquired C. difficile and MRSA infections reach multi-year highs across NHS.
Recommendation: An essential part of reducing the threat of AMR in humans is the day-to- day work of the NHS in preventing and controlling infections, such as good hygiene practices, aseptic technique and high standards of cleanliness, which can limit the …
Response attribution not verified
#21 —
Recommendation: There have been numerous media reports of PPE shortages for health and social care staff and stakeholders have told us how the failure to provide adequate and timely PPE has impacted staff morale, trust and confidence.61 In the period from …
Response attribution not verified
#13 —
Recommendation: We heard how frequently social care had taken second place to the NHS’s needs, particularly in accessing test kits and results, and securing reliable PPE supply for care homes, which had been neither timely nor coordinated.33 When questioned, the Department …
Response attribution not verified
#7 —
Recommendation: The Government must ensure that standards for weekly testing for care home staff are maintained including rapid turnaround times and that regular data is published on the number of tests delivered to social care staff and residents. In addition, the …
Response attribution not verified
#45 —
Recommendation: The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the …
Response attribution not verified
#31 —
Recommendation: The resulting requirement to abandon testing people in the community during the critical early period of the pandemic cost many lives for a number of reasons including because: a) many asymptomatic carriers were not tested and therefore identified and asked …
Response attribution not verified
#15 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Response attribution not verified
#45 —
Recommendation: The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the …
Response attribution not verified
#31 —
Recommendation: The resulting requirement to abandon testing people in the community during the critical early period of the pandemic cost many lives for a number of reasons including because: a) many asymptomatic carriers were not tested and therefore identified and asked …
Response attribution not verified
#15 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Response attribution not verified
#72 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Response attribution not verified
#46 —
Recommendation: Staff shortages, the lack of testing, difficulties in obtaining PPE and the design of care settings to enable communal living hampered isolation and infection control and the ability to keep covid at bay. Social care staff in care homes and …
Response attribution not verified
#72 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Response attribution not verified
#2 —
Recommendation: The Government provided vital additional funding to the adult social care sector during the pandemic, and we appreciate that the additional covid-19 funding cannot continue indefinitely. However, the Government’s own guidance that care workers should self-isolate if they test positive …
Response attribution not verified
#23 —
Recommendation: Care England and the British Medical Association told us that the contingency planning process for a pandemic appeared to focus on the NHS at the expense of the social care sector despite some of the most vulnerable people being in …
Response attribution not verified
#15 —
Recommendation: We welcome the proposals for a licensing scheme put forward in the Government’s consultation, including the proposed categories and the need for a practitioner to acquire appropriate indemnity cover and premises which meet the necessary standards of hygiene, infection control …
Response status not verified
CQC inspection actions(262)— showing 50 strongest matches
Westmorland General Hospital
The service should ensure staff clean the birthing pool in line with the policy for cleaning of the birthing pool, which should be reviewed, ratified and implemented to control the risk of spread of infection.
Should Do
Westmorland General Hospital
The service should ensure the policy for cleaning of the birthing pool is ratified and implemented to control the risk of spread of infection.
Should Do
Westmorland General Hospital
The service should ensure the policy for cleaning of the birthing pool is ratified and implemented to control the risk of spread of infection.
Should Do
The York Hospital
The trust should ensure that cleaning records are completed in all clinical areas.
Should Do
The York Hospital
The service must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with trust and national guidance.
Must Do
The Royal Oldham Hospital
The trust must ensure that staff in the service prevent and control the spread of infection by adhering to trust infection prevention and control policy and cleaning protocols when cleaning cubicle spaces between patients.
Must Do
The Royal Oldham Hospital
The trust must ensure that staff in the service prevent and control the spread of infection by adhering to trust infection prevention and control policy in maintaining patient and staff safety through social distancing.
Must Do
The Royal Oldham Hospital
The trust must ensure that staff in the service prevent and control the spread of infection by adhering to the trust infection prevention and control policy in the use of personal protective equipment at all times and in all areas.
Must Do
The Princess Royal Hospital
The trust should ensure the store cupboard for clean equipment is moved from the dirty utility room into the discharge lounge.
Should Do
Sunderland Royal Hospital
The trust must implement an effective system to ensure the assessment, prevention and management of infection prevention and control in the physical environment, this is recorded, monitored, and audited with actions taken to improve compliance.
Must Do
Sunderland Royal Hospital
The trust must implement an effective system to ensure the assessment, prevention and management of infection prevention and control in the physical environment, this is recorded, monitored, and audited with actions taken to improve compliance.
Must Do
Scarborough Hospital
The service must ensure their new ED has sufficient side rooms for medical staff to see and treat patients, barriered isolation rooms for infectious patients, handwash basins and storage areas for equipment.
Must Do
Salford Royal Hospital
The service must ensure that all staff follow infection control principles, including the use of personal protective equipment (PPE).
Must Do
Royal Shrewsbury Hospital
The trust should ensure that cleaning rotas are completed.
Should Do
Royal Shrewsbury Hospital
The trust should consider how it communicates the emergency department is a bare below the elbow environment to internal visitors to the department.
Should Do
Royal Shrewsbury Hospital
The trust should ensure the store cupboard for clean equipment is moved from the dirty utility room into the discharge lounge.
Should Do
Royal Hallamshire Hospital
The trust must improve infection control monitoring.
Must Do
Rochdale Infirmary
The service should ensure that cleaning schedules are completed appropriately.
Should Do
Northampton General Hospital
The trust must ensure the reduction of the risk of, and preventing, detecting and controlling the spread of, infections, including those that are healthcare associated;12(2)(h)
Must Do
Mount Vernon Cancer Centre
The trust should ensure that there are processes in place to manage the laying up of sterile instruments within the theatre areas to minimise the risk of infection.
Should Do
Mount Vernon Cancer Centre
The trust must ensure infection risks are managed and controlled.
Must Do
Montagu Hospital, Mexborough
ThetrustshouldensurethereishandgelavailablepriortoenteringthedepartmentatRetfordHospital.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatclearguidanceisinplacetoensurepigeonsdonotenterbirthingrooms.
Should Do
Montagu Hospital, Mexborough
Thetrustmustensurethatsharpsbinsaredatedandsignedonopening.Regulation12(1)(2)(g)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensureclinicalareasarekeptclean,cleaningrecordsareup-to-dateandstaffcleanequipmentafterpatientcontact,andlabelequipmenttoshowwhenitwaslastcleaned.Regulation15(1)(a)(e)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurestafffollowinfectioncontrolprinciplessuchashandhygieneandbarebelowtheelbows.Regulation12(2)(h)
Must Do
Kettering General Hospital
The service should ensure sterile water is safely stored in all areas.
Should Do
Kettering General Hospital
The service should ensure clinical areas consistently meet expected infection and prevention control measures.
Should Do
Kent & Canterbury Hospital
The trust should continue to improve compliance with COVID-19 swabbing, especially on day three.
Should Do
Fleetwood Hospital
The trust should consider improving the intensive care unit and high dependency unit isolation rooms to provide simultaneous source and protective isolation.
Should Do
Ellesmere Port Hospital
The trust must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with trust and national guidance.
Must Do
Ellesmere Port Hospital
The trust must ensure that the service meets infection, prevention and control standards and that staff adhere to those standards.
Must Do
Ellesmere Port Hospital
The trust must ensure that staff are assessing the risk of, and preventing, detecting and controlling the spread of infections, including those that are healthcare associated.
Must Do
Doncaster Royal Infirmary
The trust must ensure clinical areas are kept clean, cleaning records are up-to-date and staff clean equipment after patient contact, and label equipment to show when it was last cleaned.
Must Do
Doncaster Royal Infirmary
The trust must ensure staff follow infection control principles such as hand hygiene and bare below the elbows.
Must Do
Colchester General Hospital
The trust should ensure staff adhere to control measures to protect women, themselves, and others from infection.
Should Do
Airedale General Hospital
The service should review the use of carpets in waiting areas and evidence they are cleaned in line with infection prevention and control guidance.
Should Do
St Benedict's Hospice
The service should ensure staff use personal protective equipment when providing clinical interventions.
Should Do
St Benedict's Hospice
The service should ensure staff correctly follow infection control procedures.
Should Do
St Benedict's Hospice
The service should ensure hand hygiene audit data is collected and submitted each month.
Should Do
St Benedict's Hospice
The service should ensure all staff follow trust policy with regard to infection prevention and control.
Should Do
St Benedict's Hospice
The service must ensure measures are implemented to control the spread of infections, in line with trust policy.
Must Do
Fairfield General Hospital
The service must ensure that all staff follow infection control principles, including the use of personal protective equipment (PPE).
Must Do
East Surrey Hospital
The service must ensure infection prevention and control measures are effective and completed.
Must Do
West Berkshire Community Hospital
Makesureinfectionandpreventioncontrolpracticesareembeddedintheservice,especiallyinregardoftransporting humanwasteanddirtylinen.
Should Do
UHBW Bristol Campus
The service should ensure that hand hygiene audits are completed every month.
Should Do
St Helier Hospital and Queen Mary's Hospital for Children
The service should continue to ensure the design and maintenance of the environment allows staff to detect, prevent and control the risk of the spread of infection.
Should Do
Stamford & Rutland Hospital
The service should review departmental cleaning checklists to ensure a clear record of cleaning is kept.
Should Do
Stamford & Rutland Hospital
The service must ensure that infection control standards are improved, and that equipment and rooms that are cleaned can be easily identified.
Must Do
Royal Bournemouth Hospital
The trust should continue to raise staff awareness of the need to offer patients the facilities to wash their hands prior to meals.
Should Do
PPO death in custody recommendations(1)
IMB individual recommendations(30)
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That wall mounted sanitisers be fitted at each of the airport HR entrances.
Home Office
Askham Grange (2021)
The arrival of pods at the beginning of the pandemic meant that no one had to share rooms and that women were kept as safe as possible. The contract for keeping the pods runs out in February 2022 and they are, we are told, to be removed from the prison. The pandemic has not gone away and the women are …
HMPPS
Rejected
Swaleside (2024)
The issue of overflowing sewage from the drains must be addressed as this is exposed to the movement of food trolleys to the residential areas, which is a Health and Safety issue.
Governor / Director
Feltham (2024)
What steps are being taken to address the inconsistent cleanliness seen in the serveries, including inconsistent wearing of PPE by servery workers?
Governor / Director
Tinsley House IRC (2020)
to consider requiring the STHF to adopt a more stringent policy of compulsory facemask wearing and a more persistent approach to social distancing by detainees and staff around the centre.
Home Office
Swinfen Hall (2020)
Concerns about hygiene include: • the practice of prisoners on most wings being required to eat meals in their cells, close to a toilet (see paragraph 5.1(b)). Is there a plan to improve this? • the risk of further infestation of rats on the site, which was dangerously extensive last year (see paragraph 5.1(c)]. What mitigation measures are in place?
Governor / Director
In Progress
Oakwood (2020)
Following concerns expressed in last year’s AR, the Director should consider again, how to ensure that staff enforce the use of Personal Protective Equipment (PPE) across all houseblocks and ensure the regular availability of appropriate cleaning materials so that the serveries are maintained to a more consistent standard of hygiene and cleanliness.
Governor / Director
Woodhill (2021)
To increase efforts to improve servery hygiene and maintain the food logs on each wing.
Governor / Director
In Progress
Lancaster Farms (2021)
To take further steps to ensure that food hygiene logs are completed for each wing at each meal (paragraph 5.1.8).
Governor / Director
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That, in light of the experiences learned from the Covid-19 pandemic, detailed epidemic/infection control plans, with actions, are shared with the IMB GEL. This practice should be adopted in any further outbreaks of contagious illnesses.
Home Office
Gartree (2021)
Will the Governor ensure effective pest control measures are put in place, used and reviewed to control vermin?
Governor / Director
Swaleside (2022)
The Board is again concerned at the lack of discipline and cleanliness at wing serveries and believes that this should receive immediate attention. This approach should insist on the use of temperature probes and ‘whites’ to avoid a health risk to prisoners.
Governor / Director
Kent Coast Short Term Holding Facilities (STHF) (2024)
We recommend that the contractor liaises with Border Force to ensure that the cleaning contract for KIU, Manston marquees and Frontier House has consistent high levels of service.
Other
Implemented
Hull (2024)
The establishment leadership have applied significant focus to tackle the vermin issues within the prison. This work needs to continue to irradicate the vermin to improve the living conditions for the prisoners.
Governor / Director
High Down (2024)
The houseblock serveries continue to be left in an unacceptably dirty state. What can be done to improve hygiene standards?
Governor / Director
In Progress
Lindholme (2025)
The Board asks that the Governor considers implementing a deep-cleaning programme of the in-cell toilets.
Governor / Director
Fosse Way (2025)
As identified, under point 5.1, a concern for the IMB is the catering operation at house block level. In our opinion health, safety, hygiene and food safety on individual wings, varies with no standard procedures in place. How will the Director ensure there are unified operational standards across the prison?
Governor / Director
Lancaster Farms (2022)
To take further steps to ensure that food hygiene logs are completed for each wing at each meal, and that food temperatures are routinely logged.
Governor / Director
Isis (2020)
maintain the considerable improvement in the standard of hygiene and cleanliness that has been achieved, particularly in the houseblocks (see section 5.1)
Governor / Director
Noted
East Sutton Park (2020)
To continue with the prompt and careful steps taken to combat COVID-19.
Governor / Director
In Progress
Wetherby (2021)
Lengthy delays in maintenance work continue: for example, delays in repairing out of order cells and the never-ending saga of the kitchen floor. This is unacceptable. Throughout Covid the standard of cleanliness at Wetherby was excellent. However, as the pandemic seems to be easing, there is slippage. It would be unfortunate if this is allowed to continue. Can the Governor …
Governor / Director
Winchester (2022)
Given the continued impact of the vermin infestation, and the associated health and safety concerns, what more lasting and impactful arrangements can be made to resolve this issue?
Governor / Director
Wandsworth (2022)
Rodents and pigeons were a serious health risk to everyone in the establishment. Rats, either dead or alive, were an all too frequent sight. This was a serious matter and could lead to the spread of zoonotic diseases. What is being done to eliminate this problem?
Governor / Director
In Progress
Isis (2023)
Will the Governor ensure that the regime allows sufficient time at the end of the day to allow cleaners to properly clean the serveries and remove any uneaten food?
Governor / Director
Oakwood (2024)
How can the Director ensure that standards during service at the serveries are consistently high (hygiene, PPE, timings, equipment working correctly)?
Governor / Director
Five Wells (2024)
What steps will be taken to improve the airflow in houseblocks?
Governor / Director
Lincoln (2025)
There is still a large amount of food waste and debris outside of the accommodation wings, having been thrown from the windows. Members of the Board have witnessed material being thrown from the windows. This detritus attracts both pigeons and vermin. The Board acknowledge that these areas are regularly cleaned, however they soon become soiled again very quickly. What action …
Governor / Director
Feltham (2025)
Address the inconsistent cleanliness seen in the serveries, including inconsistent wearing of personal protective equipment (PPE) by servery workers (Feltham B Governor).
Governor / Director
Gartree (2021)
Will the Prison Service ensure that the money which has been allocated to upgrade showers is ringfenced to allow this long overdue work to take place and that there is a process put in place to test for and treat legionella in all shower blocks in the future?
HMPPS
Forest Bank (2021)
Given that currently things appear to be moving in the right direction in areas such as accommodation cleanliness, general refurbishment, enhanced security, staff and resident testing and Covid containment in particular, do you think that these results will be sustainable and ongoing when the prison returns to its full capacity, bearing in mind the staff shortages you have experienced and …
Governor / Director
In Progress
National patient safety alerts(2)
Detention investigations(5)
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R41
Healthcare should agree with how cleaning must be improved and how these new standards are adopted and maintained. Healthcare facilities should be deep-cleaned at least twice yearly. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R25
Residential DCMs and wing staff should ensure that all detainees have access to cleaning products to clean their rooms, including washbasins and toilets. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R24
Residential DCMs must hold staff to account for ensuring wings are maintained at an acceptable standard cleanliness. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R23
The SMT must resolve the issue of the inadequate cleaning of the wings either by agreeing with that it will undertake the cleaning of wings or by ensuring that wing orderlies keep wings to an acceptable standard of cleanliness throughout the day, that they are properly supervised and allowed access …
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R15
Managers should closely monitor standards of cleaning throughout the centre.
Immigration Detention
PHSO casework decisions(30)
P-001516 — The Royal Wolverhampton NHS Trust
Mrs I complained Trust staff failed to follow cross-infection guidelines, resulting in her father contracting and dying from COVID-19 in hospital.
NHS in England
Aug 2022
P-002965 — The Rotherham NHS Foundation Trust
Miss and Mr G complained the Trust gave opiate medication despite adverse reactions, prematurely discharged their mother, had poor communication, and she contracted COVID-19, leading to her death.
NHS in England
Partly Upheld
Sep 2024
P-004143 — University Hospitals Sussex NHS Foundation Trust
Mr G complained the Trust caused his mother's premature death by exposing her to COVID-19, not fast-tracking funding, discharging her with pneumonia, and withholding diagnosis information.
NHS in England
Oct 2025
P-001431 — A medical practice in the Nottinghamshire area
Mr O complained a medical practice failed to follow proper infection control when removing sutures from his shoulder, leading to an infection, further surgery, and life-changing injuries.
NHS in England
Jun 2022
P-001812 — A care home in the Sunderland area
Mrs R complained care home staff left her late father, Mr N, in urine and excrement despite paid pads, leading to skin lesions, pain, and loss of dignity.
NHS in England
Feb 2023
P-001981 — West Hertfordshire Hospitals NHS Trust
Mrs U complained her husband contracted COVID-19 at the Trust, leading to a heart attack and death. She also alleged poor hygiene care, resulting in thrush and no appropriate discharge medication.
NHS in England
May 2023
P-003846 — Nottinghamshire Healthcare NHS Foundation Trust
The Trust incorrectly followed the PICC wound cleaning procedure, causing an infection and DVT, leading to hospitalisation and distress.
NHS in England
Sep 2023
P-002638 — East Kent Hospitals University NHS Foundation Trust
Miss R complained the Trust failed to assess her father's swallow and did not isolate him, leading to aspiration pneumonia and COVID-19, which she believes contributed to his death.
NHS in England
Partly Upheld
May 2024
P-003247 — Chesterfield Royal Hospital NHS Foundation Trust
Mr B alleged his father contracted COVID-19 without treatment, was discharged without proper assessment or oxygen, experienced poor communication, and had a heart attack unrecognized for days.
NHS in England
Dec 2024
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
P-003785 — An independent provider in the Sheffield area
Miss H complained her condition deteriorated after surgery due to a haemorrhage requiring a second operation, and her wound became infected, prolonging recovery and impacting her mental health.
NHS in England
Aug 2025
P-003790 — Kettering General Hospital NHS Foundation Trust
Mrs I complained staff failed to isolate her sister, exhibited poor infection control, gave inappropriate medication, and delayed vital treatments, potentially contributing to her sister's death.
NHS in England
Aug 2025
P-004033 — Kettering General Hospital NHS Foundation Trust
Mr L complained about his late father's profound weight loss, unaddressed pressure sore, contracting COVID-19 and C. diff, poor fluid balance, unprogressed mental health referral, and ineffective pain control.
NHS in England
Partly Upheld
Sep 2025
P-003933 — Cambridgeshire and Peterborough NHS Foundation Trust
Miss D complained about her father's care by two Trusts, alleging multiple falls, contracting COVID, inappropriate medication, poor nutrition support, inappropriate restraint, lack of dignity, and issues with transfer and medication.
NHS in England
Upheld
Sep 2025
P-001456 — East Suffolk and North Essex NHS Foundation Trust
Mrs H complained her father received incorrect medication, untreated pressure ulcers, insufficient physiotherapy, unconsulted care orders, and a delayed continuing healthcare checklist.
NHS in England
Partly Upheld
Jul 2022
P-001845 — Walsall Healthcare NHS Trust
The Trust failed to protect a vulnerable patient from COVID-19, adequately monitor her, apply compression stockings, provide oral care, or follow DNACPR processes, leading to her death.
NHS in England
Dec 2022
P-001652 — Medway NHS Foundation Trust
The Trust failed to test for COVID-19 before discharge, did not ensure isolation, provided poor leg stump care, discharged an unfit patient, inappropriately implemented a DNACPR, and offered poor nutritional care.
NHS in England
Dec 2022
P-001760 — St George's University Hospitals NHS Foundation Trust
Miss B complained St George's University Hospitals NHS Foundation Trust's care, including delayed discharge, lack of vaccination, and poor communication, contributed to her mother's death.
NHS in England
Jan 2023
P-002473 — University Hospitals of Derby and Burton NHS Foundation …
Mrs H complained staff failed to treat her UTI, gave her a cervical stitch with a UTI, misinterpreted a scan, didn't remove the stitch correctly, lacked equipment for delivery, placed her with pregnant women, and sent wrong blood test results, alleging these caused her baby's death.
NHS in England
Feb 2024
P-002585 — A practice in the Kirklees area
Mrs T complained a GP used a contaminated swab during a high vaginal test, causing severe emotional distress and fear of infection, negatively impacting her relationship.
NHS in England
Upheld
Feb 2024
P-002768 — University Hospitals of Leicester NHS Trust
Mr Y complained the Trust did not follow its Carers Charter, failed to identify/communicate pneumonia, wrongly discharged his mum without communicating the procedure, and caused her to contract COVID-19.
NHS in England
Jul 2024
P-004473 — University Hospitals Birmingham NHS Foundation Trust
Mrs U complained her sister, Ms A, experienced delayed pain relief, untimely personal care, and inadequate prevention/treatment of C. difficile, which contributed to her death.
NHS in England
Upheld
Dec 2025
P-001660 — Northern Care Alliance NHS Foundation
The Trust improperly discharged a very unwell COVID-19 patient, had a COVID-positive relative collect her, provided insufficient basic care, restricted visitors, and gave unclear updates.
NHS in England
Dec 2022
P-001789 — The Rotherham NHS Foundation Trust
Mr E complained the Trust's poor management of COVID-19 positive inpatients caused his wife to contract COVID-19, leading to prolonged illness and worry for her liver condition.
NHS in England
Feb 2023
P-002002 — University Hospitals Birmingham NHS Foundation Trust
Mr Y complained his mother, Mrs Y, acquired a second infection as an inpatient and staff failed to inform him. He also criticised the Trust's complaint handling for not answering his questions.
NHS in England
May 2023
P-003472 — Walsall Healthcare NHS Trust
Miss V alleged the Trust failed to diagnose her mother's cancer in ED, delayed confirming its type, and caused a C. diff infection due to poor hygiene, potentially hastening her death.
NHS in England
Not Upheld
Mar 2025
P-003589 — Guy's and St Thomas' NHS Foundation Trust
Ms P complained she contracted hepatitis B from the Trust during surgery on March 19, 2024. This caused her anxiety, worthlessness, and loss of trust in the NHS.
NHS in England
Jun 2025
P-004245 — Barts Health NHS Trust
Mrs V complained her father developed sepsis due to poor infection control at GST Trust, and Barts Trust's ACCESS service failed to connect his chest drain, contributing to his death.
NHS in England
Oct 2025
P-001958 — Lancashire Teaching Hospitals NHS Foundation Trust
Mr A complained his father contracted COVID-19 in hospital and later died, alleging the Trust failed to implement compulsory asymptomatic staff testing soon enough.
NHS in England
Not Upheld
Apr 2023
P-002565 — The Dudley Group NHS Foundation Trust
Care after a caesarean section led to an infection and sepsis, requiring further surgery and causing a diagnosis of PTSD.
NHS in England
Apr 2024
LGO / SPSO decisions(73)
21-011-000 — East Anglia Care Homes Limited
Summary: Mr X complains his brother’s care home failed to tell him there was COVID-19 in the home, from which his brother died, and the care provider inappropriately contacted him about outstanding fees shortly after his death. The care home should have told Mr X his brother was at the …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-010-411 — Westward Care Limited
Summary: Mrs X complained about the COVID-19 protocols at her late mother, Mrs M’s, retirement village and the amount of time she received 1:1 care. There was no fault in the arrangements put in place by the Provider to prevent the spread of COVID-19 at the retirement village. The Provider …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-011-064 — Hallmark Care Homes (Banstead) Limited
Summary: Mrs X complained about events leading up to her husband, Mr X, contracting COVID-19 and being admitted to hospital. These matters have already been investigated by the Care Provider and the Council has also carried out a safeguarding investigation. Both identified fault and the Care Provider has taken suitable …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
22-001-027 — Four Seasons (No 9) Limited
Summary: Ms B complained on behalf of Mr & Mrs C about the care they received from Four Seasons (No 9) Ltd when it operated a care home they were both resident at; in Mrs C’s case with that care provided on behalf of the Council. We uphold the complaints, …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-004-573a — Cedars Place Care Home (21 004 573a)
Summary: Mrs B and Mrs C complained about the way the Trust cared for their late father, Mr D, when he was in hospital in December 2021 and contracted COVID-19. They also complained about the way the Council and Trust dealt with Mr D’s discharge to a care home, and …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2022
21-018-582 — Ashall Care Ltd
Summary: Mrs X complained about the short-term respite care her father, Mr Z, received at Farthings Residential Care Home which is owned by Ashall Care Ltd. The care provider has already found it failed to properly check Mr Z’s room when he moved in and did not explain how to …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
20-007-315 — HC-One Oval Limited
Summary: Mrs X complains HC-One Oval Limited’s Lyndon Hall Nursing Home failed to look after her late mother properly and failed to keep her family informed about the deterioration in her condition before she died, causing unnecessary distress. HC-One accepts Lyndon Hall failed to deal properly with two falls and …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-009-170a — The Old Hall - Spilsby Care Home (20 …
Summary: Mrs A complains about the care of her mother, Mrs B at a care home. She has also complained about a council’s safeguarding enquiries. We found fault in relation to the Home’s lack of mask wearing. We did not find fault with the other issues in this complaint.
LGO (Local Government & …
Health
Upheld
May 2022
21-000-034 — Cheshire East Council
Summary: Ms B complained on behalf of Mr & Mrs C about the care they received from Four Seasons (No 9) Ltd when it operated a care home they were both resident at; in Mrs C’s case with that care provided on behalf of the Council. We uphold the complaints, …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-014-447 — Plymouth City Council
Summary: Miss X complains about the care her grandmother, Mrs Y, received at Greenacres Care Centre, where the Council placed her for respite care. The Council accepts there were examples of poor care and poor communication with Mrs Y’s family. It needs to apologise to her family and make a …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-009-369 — North East Lincolnshire Council
Summary: Miss X complains the Council’s blanket ban on care home residents visiting people outside a care home when there were cases of COVID-19 in the care home prevented her father from visiting her on a number of occasions since September 2021. Based on the evidence seen so far, the …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-014-934 — Ebury Court Residential Home Limited
Summary: Mr X complained about the care his late mother, Mrs Z, received during the last few weeks of her life at Ebury Court Residential Home during the COVID-19 pandemic. There was no fault in the updates the Care Home provided the family, its care of Mrs Z, or how …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2022
21-016-658 — Calsa Care Limited
Summary: Mrs X complained about the visiting arrangements Calsa Care Ltd had in place during the COVID-19 pandemic, its refusal to award her essential care giver status and its decision to give her mother, Mrs M, notice. She also complained about the care Mrs M received at the end of …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
202104888 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about the care and treatment that their late parent (A) received from the board following A’s admission to hospital having suffered a stroke. A developed COVID-19 symptoms and this was confirmed by a positive swab. A’s condition deteriorated with them developing COVID-19 pneumonia and they sadly died. C …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2024
21-000-498a — Lynwood Care Centre (21 000 498a)
Summary: The Ombudsmen found no fault by a Council, a CCG and a care home in relation to the nutritional support and personal care provided to Mrs Y. We have found fault with how nutritional risk was assessed, but this did not affect the care provided and the care home …
LGO (Local Government & …
Health
Not Upheld
Jan 2022
21-004-468 — East Sussex County Council
Summary: Mr X complains the Council failed to provide transport to his son’s day centre, sent a reminder for an invoice it had not sent and expected his son to pay for services he did not receive because of COVID-19. He says this left his son without support and his …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-003-450 — Warrington Council
Summary: Mrs X complains the Council left her mother, Mrs Y, in residential care for too long, resulting in her paying too much for her care. The length of time Mrs Y spent in residential care was due to COVID-19, not fault by the Council. However, the Council failed to …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-007-453 — Birmingham City Council
Summary: There was no fault by the Council in its decision to suspend part of its pest control service during the COVID-19 pandemic. This was a decision it was entitled to take, and we have no grounds to question it. The Council’s handling of the complainant’s complaint was poor, but …
LGO (Local Government & …
Environment And Regulation
Upheld
Feb 2022
21-004-752 — Boutique Care Shepperton Ltd
Summary: Ms X complains about the care her mother, Mrs Y, received at The Burlington, a care home run by Boutique Care Shepperton Ltd. She says this resulted in having to move her mother and paying for two care homes. The Burlington’s actions contributed to the breakdown in relations between …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-000-364 — Essex County Council
Summary: Mr B complained the Council wrongly and repeatedly sent invoices to his mother, Mrs C, for care charges she did not owe, leading her to take her own life. We uphold the complaint, with the Council having acknowledged that it wrongly failed to identify Mrs C’s case as one …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-010-783 — Gloucestershire County Council
Summary: Mr S complained the Council and Trust failed to ensure his father, Mr F, was properly discharged from hospital into residential care. He also complained the Council failed to assess Mr F’s care and support needs. We have found fault in the actions of both organisations. We recommended financial …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-013-739 — Lancashire County Council
Summary: Mr X complains the Council failed to deal properly with Mrs Y’s move to Aadamson House Care Home, where she received inadequate care. The Council has apologised for the way it dealt with Mrs Y’s move to the Care Home. It also accepts the care she received there put …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-012-996 — Stonehaven (Healthcare) Ltd
Summary: Mrs N complained about the actions of Stonehaven Healthcare Ltd in relation to its care of her uncle, Mr X, during the COVID-19 pandemic. The Care Provider was at fault when it gave Mr X notice without first exploring alternative options. This caused Mr X uncertainty about whether the …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-000-741 — Barchester Healthcare Homes Limited
Summary: Mrs J complained about the care her mother received while she was resident at Meadowbeck Care Home operated by the Care Provider. Among other matters, Mrs J complained she had only very limited opportunity to visit her mother before she died of COVID-19 in May 2020. We uphold the …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
22-000-692 — Lancashire County Council
Summary: Ms X complains the Council failed to deal properly with her financial assessment by failing to respond to telephone communications and correspondence, and by failing to make reasonable adjustments to reflect her needs, resulting in it imposing charges which she could not afford to pay and taking 10 months …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
24-014-250 — London Borough of Wandsworth
Summary: Mrs X complained the Council failed to act when she contacted it with concerns about her late brother’s care and it was difficult to get in contact with anyone. She also complained the care home the Council commissioned failed to get an air mattress for her late brother before …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
201004951 — Fife NHS Board
Mrs A was admitted to hospital on numerous occasions in the two years before her death. She had a complex medical history and tested positive for a bacterial infection, Methicillin-resistant Staphylococcus aureus (MRSA), on six occasions during that time. Mrs A's daughter (Mrs C) complained that the board failed to …
SPSO (Scottish Public Se…
Health
Not Upheld
Aug 2012
201708720 — Lothian NHS Board - Acute Division
Mrs C complained about the care her mother (Mrs A) received at St John's Hospital. Mrs C complained about the number of ward moves that Mrs A experienced. Mrs A had dementia and Mrs C said that the number of ward moves caused Mrs A to become disorientated. Mrs C …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2018
20-006-183 — Coventry City Council
Summary: Mr D complains the Council’s adult social care team failed to help him deal with his council tax benefits or to get food during the first coronavirus lockdown in 2020. The Council did not send Mr D a copy of his care and support assessment, but this did not …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
20-010-131 — Sandwell Metropolitan Borough Council
Summary: Miss X said the Council failed to investigate her complaint about the smell caused by clinical waste bins from a neighbouring care home. We have seen nothing to indicate the Council knew about Miss X’s concerns before she complained to the Ombudsman. The Council was not at fault. However, …
LGO (Local Government & …
Environment And Regulation
Upheld
Jan 2022
21-007-248 — Warwickshire County Council
Summary: Mrs X complains the Council failed to deal properly with the family’s request for a discretionary 12-week property disregard for her mother-in-law. The Council failed to explain the reasons for not granting a discretionary 12-week property disregard. This creates doubt over whether it made the right decision. To remove …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
20-012-246 — Hampshire County Council
Summary: Mr X complained about the care received by his father, Mr F, when he was at Ashley Lodge Care Home. The Care Provider and Council have already admitted some of the record-keeping was poor. The Council should ensure staff at the Care Home are reminded of the importance of …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-001-705 — West Sussex County Council
Summary: Ms X complained the Council failed to provide adequate support for her daughter, Miss D. She also complained the Council stopped Miss D’s direct payments in February 2020 and November 2020 for no good reason and refused to reimburse her for activities and items she had bought on behalf …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-003-087 — West Northamptonshire Council
Summary: Ms X complained the Council failed to ensure her son, Mr Z, received appropriate care, and also failed to complete his mental capacity assessment and care and support reassessment. The Council was not at fault in relation to these matters. However, it is at fault for delaying in making …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-006-662 — Newcastle upon Tyne City Council
Summary: The Council failed to provide Mr X with the support he needed to complete assessment forms for disability related expenditure and then communicated poorly about this with Mr X’s representative. The Council has apologised for the faults and agreed to consider backdating any allowance for disability related expenditure it …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-012-935 — Sefton Metropolitan Borough Council
Summary: Dr X complains the Council has failed to provide her daughter with the support she has been assessed as needing. The Council has failed to meet all her daughter’s needs, causing avoidable distress. The Council needs to apologise, involve Dr X in assessing her daughter’s needs and pay financial …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-010-265 — Cheshire West & Chester Council
Summary: Mrs X complains about the charges for her son’s care after he left a care home to live with his family because of COVID-19. Although the Council agreed to waive 50% of the charge, Mrs X says this left her son without enough money to contribute towards the family’s …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-006-872 — London Borough of Brent
Summary: Dr X complains the Council failed to deal properly with his late father’s care needs from May to November 2020, at times failing to meet them and causing unnecessary distress. The Council did not fail to meet the father’s needs. However, it caused avoidable distress by failing to respond …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-016-909 — Tameside Metropolitan Borough Council
Summary: Mr X complains the Council failed to deal properly with the charges for his mother’s care,
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-012-231 — Cornwall Council
Summary: Mrs X complains the Council has failed to meet her daughter’s assessed need to attend day services since they were allowed to reopen in 2020, which has caused her avoidable distress. The Council delayed in reviewing her daughter’s needs, then failed to review them properly and provided misleading and …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
20-014-148 — Stockport Metropolitan Borough Council
Summary: We have upheld complaints from Ms D, Ms K and Ms F about the actions of the Council, Home and Integrated Care Board in connection with the care of their late mother, Mrs M.
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-019-063 — Shropshire Council
Summary: We found no fault by a Council and ICB with regards to how they assessed Mrs Y’s needs following her discharge from hospital. However, we found fault with the Council’s complaint response which incorrectly advised Mrs Y’s son that a Continuing Healthcare Checklist had been completed when it had …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-009-880 — Hertfordshire County Council
Summary: Mr A complained professionals from a Council and Trust inappropriately interfered with his wife’s package of care when she left hospital in April 2021. We found fault in how professionals worked out what was in Mrs A’s best interests. However, on balance, this did not lead to an injustice.
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
21-018-733 — Methodist Homes
Summary: Ms X complained the Care Provider refused to award her essential care giver status, lied about her to her siblings, made her carry out her COVID-19 lateral flow tests on site and failed to deal appropriately with her complaints. She says this caused her and her mother distress. There …
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2022
22-003-541 — Cambridgeshire County Council
Summary: Mr X complained about Cambridgeshire and Peterborough NHS Foundation Trust (the Trust) and Cambridgeshire County Council (the Council). He complained about faults in his discharge from hospital, reablement, and referrals for community therapy services. He also complained about the Council’s complaint handling. We have upheld parts of the complaint …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
24-009-211b — Spencer Grove Care Home (24 009 211b)
Summary: Mrs A complains about the way the Care Home and GP Practice cared for her mother, Mrs B. We will not investigate this complaint because we are unlikely to achieve anything more. This is because the coroner has already looked at the issues, and there has already been an …
LGO (Local Government & …
Adult Care Services
Nov 2024
24-009-211 — Milford Care Limited
Summary: Mrs A complains about the way the Care Home and GP Practice cared for her mother, Mrs B. We will not investigate this complaint because we are unlikely to achieve anything more. This is because the coroner has already looked at the issues, and there has already been an …
LGO (Local Government & …
Adult Care Services
Nov 2024
201102400 — Highland NHS Board
Mrs C was admitted to hospital for a gastroscopy (a procedure in which a thin, flexible tube is used to look inside the stomach) under general anaesthetic. She waited in the day room until she was allocated a bed. During this time a member of staff discussed confidential information with …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2012
201400264 — Highland NHS Board
Ms C, an advocate, complained on behalf of her client (Mr A) about the infection control procedures used by Raigmore Hospital when he had a total hip replacement. When Mr A attended the pre-operative assessment when he was first scheduled for surgery, it was found that he had an in-growing …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2015
202104334 — Lothian NHS Board - Acute Division
C complained about the care and treatment their late parent (A) received. A had a diagnosis of small cell lung cancer and was transferred to the Western General Hospital for urgent treatment of metastatic lung cancer. This was during the first year of the COVID-19 pandemic. Shortly after A's admission, …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2022
CJINI inspection reports(1)
CQC enforcement actions(4)
Warning Notice: Barts Health NHS Trust
The Care Quality Commission issued three formal warning notices to Barts Health NHS Trust following unannounced inspections at Whipps Cross University Hospital in May and June. The warnings required urgent improvements to protect patients and addressed the hospital's non-compliance with …
Whipps Cross University Hospital
Aug 2013
Warning Notice: Medway NHS Foundation Trust
The Care Quality Commission has formally warned Medway NHS Foundation Trust that it needs to improve the care it provides to patients in the emergency department at Medway Maritime Hospital, Gillingham. CQC issued warning notices to the trust after an …
Medway Maritime Hospital, Gillingham
Mar 2014
Warning Notice: East Sussex Healthcare NHS Trust
The Care Quality Commission rated East Sussex Healthcare NHS Trust as Inadequate overall following an unannounced inspection in March 2015. The trust was told it must make improvements in 12 main areas, including rebuilding effective relationships with staff, creating an …
Sep 2015
Warning Notice: Leeds Teaching Hospitals NHS Trust
Section 29A warning notice covering maternity and neonatal services at Leeds General Infirmary and St James's University Hospital, following unannounced inspections in December 2024 and January 2025. CQC identified breaches relating to learning from incidents, risk management, the safety of …
Leeds General Infirmary and St James's University…
Jun 2025