Care home social isolation
Residents in care homes being at risk of social isolation due to an insufficient provision of engaging activities.
Source spread
Where this theme appears
This theme appears across 10 independent accountability sources, so the source mix matters as much as the headline total.
4 inquiry recs
4 PFD reports
6 committee recs
36 CQC actions
38 IMB recs
2 Article 2 learning points
2 DHR recs
2 PHSO decisions
14 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)
39 — Co-ordinator of voluntary services
Recommendation: A paid co-ordinator of voluntary services should be appointed and local community participation in the hospital’s activities developed by every possible means.
Unknown
38 — Improve transport to and from Preston
Recommendation: To assist visiting by relatives and recruitment of staff there should be a considerable improvement in transport facilities to and from Preston and the surrounding area.
Unknown
37 — Unrestricted daily visiting
Recommendation: Truly unrestricted daily visiting, which does not exist at present, should be introduced as soon as possible.
Unknown
R21 — Nursing staff for relatives
Recommendation: Health Boards should ensure that a member of nursing staff is available to deal with questions from relatives during visiting periods.
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
Prevention of Future Deaths reports(4)
Sheila Graham
Concerns: The coroner noted an apparent lack of policy for referring patients in prolonged social isolation to mental health services, with a referral occurring only after family prompting. There were also discrepancies between nursing nutrition records and the observed practice of the catering team, alongside a delay in dietician referral despite patient weight loss.
Overdue
Charlotte Duffield
Concerns: The coroner noted that despite a referral to Adult Social Care due to significant safety concerns, no safeguarding action was taken, particularly after the individual did not respond to telephone contact and no in-person visit was made.
Response (Cumbria County Council): • Cumbria County Council completed a systematic review of its self-neglect policy and procedure documentation. • Operational practice guidance for self-neglect concerns was reviewed and revised to reinforce the requirement … (AI summary)
Responded
Helena Opuku
Concerns: The London Borough of Redbridge adult social care team was unable to properly investigate most safeguarding referrals, appoint social workers in a timely manner, or carry out home suitability assessments for vulnerable residents during January-March 2021.
Overdue
Margaret Stringer
Concerns: The care home lacked a documented system to restrict residents' access to items and staff awareness of isolation's impact on elderly mental health was insufficient. Gaps in information transfer about the resident's suicide risk were also noted.
Response (Adult Community Social Care): • The format of the overview document (A1253) will be reviewed. • A strength-based approach framework is planned to be rolled out across all Adult Social Care teams within the … (AI summary)
Response (Blackpool Teaching Hospitals NHS Foundation Trust): • Blackpool Teaching Hospitals NHS Foundation Trust (BTHFT) attended a meeting with Lancashire and South Cumbria NHS Foundation Trust (LSCFT) to consider alignment of expectations for communication and information sharing. … (AI summary)
Response (DAC Beachcroft): • The care home stated that residents with a similar history would no longer be admitted. • It confirmed that a system of 1:1 care would be implemented for at-risk … (AI summary)
Responded
Select committee recommendations(6)
#7 —
Recommendation: While the secure video calling service is a temporary measure implemented in direct response to the changes across the estate resulting from Covid-19, the Committee 28 Coronavirus (Covid-19): The impact on prisons believe there is scope for this service to …
Response attribution not verified
#6 —
Recommendation: It is vital that prisoners are able to maintain contact with family and friends, particularly at such an uncertain time. Family contact is essential to a prisoner’s wellbeing and resettlement, and we welcome measures taken to ensure that prisoners are …
Gov response: HMPPS fully recognise the importance of maintaining family contact for prisoners. This is why we quickly introduced video calling when the exceptional circumstances meant social visits were temporarily suspended in March and where they continue …
Position Not Stated
#7 —
Recommendation: With many people preferring to stay living at home if diagnosed with dementia, it is vital that any future Government strategies for dementia support this becoming a reality. Initiatives such as Dementia Friends and dementia-friendly communities have successfully increased awareness …
Response status not verified
#2 — Rural isolation creates significant mental health challenges for residents and agricultural workers.
Recommendation: While experience of nature and the countryside is consistently identified as potentially beneficial for people’s mental health, our evidence is equally clear that the isolation inherent in rural living poses a significant challenge to the mental health of those who …
Response attribution not verified
#8 —
Recommendation: DHSC told us it recognised that advising people to stay inside and away from society does have risks as well as benefits. Of those surveyed, some 36% reported worsening mental health and wellbeing while shielding.14 Charities also told us of …
Response attribution not verified
#33 —
Recommendation: Joining a sports club, community walking club or a leisure centre is a wonderful way to meet new people in the community and to make connections. When local people come together through sport and physical activity, further benefits follow, from …
Response attribution not verified
CQC inspection actions(36)
Brook House
We recommend the registered provider enables people to access more individualised meaningful activities to help reduce the risk of social isolation.
Should Do
Oaklands Care Home
People were at risk of social isolation due to a lack of activities on offer to them.
Must Do
Walnut Close
The provider did not always support people to avoid social isolation and partake in meaningful activities.
Must Do
Darenth Grange Residential Home
The provider should offer a wider range of opportunities for people to engage in social activities.
Should Do
Oaklands Care Home
The provider must ensure people are not at risk of social isolation due to the lack of activities and meaningful interactions available to them.
Must Do
The Peter Gidney Neurodisability Centre
There was a lack of meaningful activities for some people.
Must Do
Newland House
People's individual needs were not being met in relation to the provision of activities and social stimulation.
Must Do
The Croft
People did not have access to their own personal allowances, petty cash or transport to enable them to access the community.
Should Do
Oakleigh House Nursing Home
There was a lack of appropriate activities offered which would meet people's needs. Regulation 9 (1) (a) (b).
Must Do
Bellevue Healthcare Limited
The provider must ensure people's privacy and dignity are consistently maintained, and that people are not isolated and have appropriate means to communicate and call for assistance.
Must Do
Chandos Lodge Nursing Home
The service seeks advice and guidance from a reputable source about the provision of meaningful interaction and engagement.
Should Do
WhiteHorse Care - Brownhills
Further improvements were needed to the range of activities and opportunities for people.
Should Do
Walnut Close
The service's quality assurance systems did not identify shortfalls regarding people's social needs, the environment and mental capacity assessments.
Must Do
The Lilacs Residential Home
The provider should ensure that there is a dedicated activities person to ensure people are supported to take part in activities that are socially and culturally relevant to them.
Should Do
The Elms
We recommend the provider continues to review social activities in the service to promote people's emotional and mental wellbeing.
Should Do
St. David's Home
We recommend the provider consider current guidance on the provision of meaningful activities to promote people's wellbeing and review their practices accordingly.
Should Do
Oak Tree Manor
When supporting people living with dementia they may need to consider being more creative for people who had become more of a challenge to get engaged in activity and communication to avoid social isolation.
Should Do
Meads House Residential Care Home
We recommend that the provider seeks advice and guidance from a reputable source to ensure that the activities offered are more conducive to people living with dementia on a daily basis.
Should Do
Lauren Court Residential Care Home
We recommend the provider reviews how to engage and support people who choose to remain in their bedroom.
Should Do
Hamilton House
We recommend the provider researches and develops the social opportunities for people living with dementia and mental health in line with best practice.
Should Do
Elton Lodge
The provider should ensure that people are engaged in meaningful activities with sufficient frequency, and review policies that discourage staff interaction during breaks if it benefits residents' engagement.
Should Do
Rosecroft Residential Care Home
The provider should consistently provide meaningful activity for people using the service.
Should Do
Quality Care Management Limited
The provider should seek current guidance, review the arrangements in place to ensure people are always supported to avoid social isolation, follow interests and take part in activities that are socially and culturally relevant to them and update their practice.
Should Do
Barton Park Nursing Home
The service reviews their process for recreational activities for people and takes action accordingly.
Should Do
Chiltern View
The provider must ensure people receive person-centred care, that care plans are followed, people's preferences are observed, and that people are not isolated and have meaningful engagement or occupation.
Must Do
Pinhoe View
The provider must ensure privacy frosting does not obscure patients view of the outdoors. This meant that did not have a direct link to the outside community.
Must Do
Eastside House
We recommend the service continue to review the range of activities taking place for people.
Should Do
Cymar House
We recommend the provider reviews their activity provision, in particular for people living with dementia, and implements best practice guidance in this area.
Should Do
We Can Recover CIC
The service should ensure there are enough activities for clients to minimise lethargy.
Should Do
The Elms
The provider should consider how they may better support people with activities that they wish to take part in and ensure that a consistent approach to this is maintained.
Should Do
Park Grange Care Home
The care plans we looked at did not contain sufficient information to help staff to provide person centred care and there were limited activities for people.
Must Do
The Warren Residential Lodge
it was not always clear whether people were aware of these [activities] or if the activities were always in line with people's preferences.
Should Do
The Warren Residential Lodge
Activities were available for people though some people were not always aware of these.
Should Do
Snowdrop Place Care Home
The provider should review best practice guidance related to care home environments to promote independence for people, including people living with dementia or disability.
Should Do
Snowdrop Place Care Home
The provider should review and implement all relevant best practice guidance in respect of care home environments to promote all people's independence.
Should Do
Eleanor House
The provider must take action to ensure there were sufficient numbers of suitably qualified, skilled and experienced staff available at all times. This was to ensure people who used the service were provided with appropriate meaningful opportunities for social interaction …
Must Do
IMB individual recommendations(38)
Wayland (2023)
The IMB would recommend that prison management review the issue [loneliness] to examine other prisons’ experiences and, possibly, knowledge of how to address this issue successfully.
Governor / Director
Isle of Wight (2024)
Given the older prisoner demographic, could funds be allocated to enable the charity, Age UK, to attend on site and continue its valuable work in relation to prisoner welfare and dementia?
Governor / Director
Drake Hall (2020)
The prison should consider how to enhance the use of Purple Visits to ensure that family contact is optimised during the pandemic.
Governor / Director
Wayland (2021)
The Board’s findings that 35% of the prisoner community respondents felt that they could trust no other prisoner and of those who could trust others, an average of only three others suggests that there is an urgent need for more detailed research, and a strategic response then identified, to this situation (see section 4. Introduction).
Governor / Director
Heathrow Immigration Removal Centre (2021)
DET should immediately restore face-to-face contact by the engagement officers and systematically track its occurrence.
Home Office
Drake Hall (2021)
The Board looks forward to seeing an increase the number of social visits, pandemic permitting (see section 7.4).
Governor / Director
Durham (2022)
Social video calls have been reduced to one per month per prisoner. What can be done to increase access for those living out of area or from overseas (7.4.6)?
HMPPS
Thorn Cross (2023)
To provide mobile phone access for remote visits for those who would benefit (7.4.3).
HMPPS
Partially Accepted
Drake Hall (2023)
The Board would encourage identifying those women who are isolated from family and friends and creating a programme to support them.
Governor / Director
North West and Midlands STHF (2024)
Television for use by persons being detained is not available for persons in East Midlands airport (see section 2.3.2.2). Television can have a calming effect and distraction for persons being detained. The Board recommends that a television is fitted.
Home Office
North Sea Camp (2024)
To maintain family ties, consideration should be given to providing in-cell telephony. Prisoners often arrive from previous establishments where this is readily available, sometimes alongside restricted PC access.
HMPPS
Partially Accepted
Isle of Wight (2024)
Given the barriers to family social visits caused by the prison’s location, can the Governor maximise social video call opportunities by ensuring that monitors are available in each wing in Parkhurst? Also, could a review of any unmet needs and available technologies be undertaken with a view to increasing the number of daily and weekend social video call slots available?
Governor / Director
Altcourse (2024)
Is there any timescale for re-opening the creche in the visits hall?
Governor / Director
Wayland (2025)
We recommend to the Prison Service long term planning directorate that prisoners held far from London might have an opportunity for what used to be the reasonably common practice of ‘accumulated visits’ (where visitors can accumulate a certain number of visits over a specified period, typically 12 months, to receive visits at a different prison closer to their family).
Governor / Director
Noted
Wayland (2025)
Throughout the years of our surveys a significant number of respondents have been willing to say that they have indeed felt lonely in Wayland. The IMB would, therefore, ask if staff are aware of how lonely many prisoners are. Of course, the loneliness quotient may ebb and flow in any one person, but surely it must be a component of …
Governor / Director
The Mount (2025)
The Governor should introduce a trial to increase the number of family visits for enhanced prisoners to see if it is welcomed by prisoners and has the potential benefits in terms of their behaviour.
Governor / Director
In Progress
Onley (2020)
Far from home. Although HMP Onley has moved into the East Midlands group, it is predominantly prisoners from London and the South-East who are being transferred there. Onley is a prison with poor transport links. This combination of factors has a severe impact on the ability of prisoners’ families to visit them, and undermines attempts to provide stability and continuity, …
HMPPS
In Progress
Drake Hall (2020)
The Board is concerned about the impact of shielding on the long-term wellbeing and rehabilitation prospects of prisoners in the Truro unit.
Governor / Director
Brixton (2020)
the inadequate emphasis on maintaining family ties, especially in prisons like Brixton without in-cell telephony.
Other
In Progress
Wayland (2021)
In the Board’s view, the expected benefit of ‘Purple Visits’ has not been fully realised due, prisoners have informed us, to the conditions imposed on relatives. It therefore urges the Prison Service to review these arrangements to find consumer-acceptable alternatives to face-to-face social and family visits (see section 7.4).
HMPPS
Rejected
Thorn Cross (2021)
The staffing detail should be looked at to see how in person and virtual (phone and video) visits can be maintained.
Governor / Director
Dartmoor (2021)
Expand the Purple Visits system to the benefit of more prisoners and their families, given Dartmoor’s remote location.
Governor / Director
Brinsford (2021)
Visits need to return to pre-pandemic levels as soon as it is safe. Purple Visits have been useful and should be continued for any prisoners who cannot receive face-to-face visits.
Governor / Director
Wayland (2023)
The IMB suspects that this important contingent of a prisoner’s social life, and therefore his social health, is not given the attention it needs and would recommend that prison management review the issue to examine other prisons’ experiences and, possibly, knowledge of how to address this issue successfully.
Governor / Director
Belmarsh (2023)
Will HMPPS work with Belmarsh management to develop and implement a system of in-cell phones in HSU to allow prisoners privacy and access to their families and their legal teams?
HMPPS
Altcourse (2023)
What are the plans for improving the daily regime for prisoners, and in particular, when can they expect to eat their meals outside of their cells and in association with other prisoners?
Governor / Director
Stoke Heath (2024)
When will the Governor prioritise the need for more social video calls during weekends and evenings, for example, to allow prisoners to have contact with their families.
Governor / Director
In Progress
Gatwick IRC (2024)
Revise lock-in times to provide the detained men more association time.
Home Office
Rejected
Wayland (2025)
It might also be helpful if some training could be devised for operational staff to give them greater confidence in discussing this issue, say, within their key-working responsibilities. The Board would so recommend.
Governor / Director
Highpoint (2020)
The Board recommends that consideration is given to the continuation of purple visits (a secure video calling platform) after restrictions are lifted. This would provide an alternative means of family contact where distance makes visiting difficult. (See 7.4.3)
Governor / Director
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2020)
That the proposed partitioning at Larne House STHF does not prevent detainees from the opportunity to socialise, during the day. We have not, however, been informed about the timescale for this work. We ask that the work be appropriately planned with clear, transparent and realistic timelines and that this information is shared with the Board.
Governor / Director
Buckley Hall (2022)
Introduce a range of social activities during prisoners’ evening association.
Governor / Director
Ashfield (2022)
reviving the highly successful AshFest?
Governor / Director
Ashfield (2022)
Can the Director consider reviving the prison magazine?
Governor / Director
Ashfield (2022)
Can the Director consider literacy related activities such as poetry reading, book club, etc?
Governor / Director
Stoke Heath (2024)
The Governor should prioritise the need for more social video calls during weekends and evenings, for example, to allow prisoners to have contact with their families.
Governor / Director
Hollesley Bay (2024)
The sensory garden adjacent to Samford unit is a welcome addition. The Board looks forward to its continuing development.
Governor / Director
Buckley Hall (2024)
Concerns have been raised about the restrictive timing of the social video calls, which impact on a family’s ability to utilise them.
Governor / Director
Article 2 learning points(2)
— LP 3
We recommend that there should be a requirement in place that some means of distraction should always be offered to prisoners in court custody suites.
HMPPS
Accepted
— LP 5
We recommend that the facility of a social visit for newly convicted prisoners should apply equally to newly sentenced prisoners who have previously been at liberty on bail.
HMPPS
Accepted
Independent reviews(2)
Shaw Detention Review — Rec 30
Recommendation 30: The internet access policy should be reviewed with a view to increasing access to sites that enable detainees to pursue and support their immigration claim, to prepare for their return home, and which enable them to maximise contact with their families. This should include access to social media.
Immigration
Selous Review — Rec 93
The Armed Forces and the Ministry of Defence to: • encourage small acts of kindness, including a welcoming committee to engage with families moving into a new area • promote pro-active support to enhance wellbeing through a family centre/family hub on every military base as the safe ‘go to’ place …
Other
PHSO casework decisions(2)
P-001353 — Royal Free London NHS Foundation Trust
Miss G complained her mother was discharged without sufficient diagnosis information, necessary equipment, and family visits were denied due to COVID-19 restrictions.
NHS in England
Apr 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
LGO / SPSO decisions(14)
24-020-734 — Wigan Metropolitan Borough Council
Summary: There was fault by the Council. It did not act soon enough to resolve Mrs X’s risk of social isolation when she had to live in part of a care home without other residents. Her son, Mr Y has acted on her behalf and this caused him distress. The …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
24-014-830 — MML Finance Ltd
Summary: Mrs X complained that the care provider restricted her visiting hours to her mother-in-law. Based on current evidence the complaint will not be upheld. The care provider was entitled to limit the times for Mrs X’s visits.
LGO (Local Government & …
Adult Care Services
Not Upheld
Apr 2025
22-001-008 — Bingley Wingfield Care Limited
Summary: We will not investigate this complaint that a Care Home stopped Mr X’s visits to a relative. That is because there is insufficient evidence of fault in the Care Home’s actions to justify investigating.
LGO (Local Government & …
Adult Care Services
May 2022
22-002-358 — Derbyshire County Council
Summary: We will not investigate this complaint about Mr X’s contact with his friend in a care home. This is because the Council have agreed to complete an assessment and further investigation would not lead to a different outcome.
LGO (Local Government & …
Adult Care Services
Jun 2022
24-005-899 — London Borough of Islington
Summary: We will not investigate Mr X’s complaint about his care placement. He says he is unhappy living there due to problems with another resident and the care provider. Mr X also complains the Council is ignoring his request to move. This is because there is insufficient evidence of fault.
LGO (Local Government & …
Adult Care Services
Oct 2024
24-017-348 — City of Bradford Metropolitan District Council
Summary: Mrs X complained about the Council’s handling of her child’s Education, Health and Care Plan, which she said led to a loss of education and social isolation for her child. We found avoidable delay by the Council in completing the 2024 Annual Review of the Plan. The Council also …
LGO (Local Government & …
Education
Upheld
Nov 2025
25-020-404 — Aria Healthcare Group LTD
Summary: We will not investigate this complaint about a care home declining to allow Mrs X to visit a resident. The resident is represented by her family and there is no evidence they or she wishes Mrs X to visit. Investigation would be unlikely to serve any worthwhile purpose.
LGO (Local Government & …
Adult Care Services
Nov 2025
24-021-776 — London Borough of Haringey
Summary: Miss X complains the Council failed to arrange a day centre placement for her son, Mr Y. She also complains about the Council’s poor communication. The Council failed to arrange a day centre placement for Mr Y after it was approved in April 2024 until March 2025. It then …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
PSOW-202001667 — Denbighshire County Council
Mr D complained about the care and treatment that his late mother, Mrs M, received at Glan Clwyd Hospital and Llandudno General Hospital. He complained that: Clinicians failed to adequately investigate and appropriately treat Mrs M’s symptoms of abdominal pain, gastro-intestinal upset and weight loss which she developed following bowel …
PSOW (Public Services Om…
Local Government
Jul 2021
23-011-145 — East Sussex County Council
Summary: Miss X complained the Council failed to provide a suitable education for her son for the past four years causing distress and social isolation. The Council failed to provide any education provision from May 2023 to January 2024, wrongly requested Miss X put a review request in writing causing …
LGO (Local Government & …
Education
Upheld
Apr 2024
24-008-236 — Surrey County Council
Summary: We will not investigate this complaint about a blue badge application. There is not enough evidence of fault to justify our involvement.
LGO (Local Government & …
Adult Care Services
Nov 2024
201300330 — Dunedin Canmore Housing Ltd
Ms C complained to the housing association about various types of antisocial behaviour by a neighbour. She complained that the association had failed to deal appropriately with her complaints and had unreasonably failed to carry out their promise to fix her neighbours flooring to limit household noise causing disturbance to …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Mar 2014
201205406 — Falkirk Council
Ms C, who is a solicitor, complained on behalf of her clients (Mr and Mrs A) that the council did not reasonably investigate reports of antisocial behaviour by a neighbour, who is a council tenant, and about whom there had been many other complaints. Ms C wrote to the council …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Mar 2014
25-009-946 — London Borough of Hammersmith & Fulham
Summary: We will not investigate this complaint about adult social care at a day centre. This is because an Ombudsman investigation would be unlikely to lead to a different outcome and it is unlikely we would find any significant fault to justify our resource.
LGO (Local Government & …
Adult Care Services
Jan 2026
Domestic Homicide Reviews(2)
Leicester — recommendation WALL - 4
Welfare calls to be made to refuge residents before 12 noon each morning.
Women’s Aid Leicestershire Ltd (WALL)
Lancaster — recommendation 4
To review the potential for isolation in the current environment of the Single Point of Access team in Lancaster and Morecambe – small office, lone working
Lancashire Care NHS Foundation Trust
Lancashire and South Cumbria …