Care home staffing levels
Insufficient numbers of suitably skilled and experienced staff deployed in care homes, impacting ability to meet resident needs.
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.
11 inquiry recs
162 PFD reports
27 committee recs
90 CQC actions
6 PPO recs
3 IMB recs
15 IMB reports
2 Scottish FAIs
5 detention investigation recs
4 PHSO decisions
407 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(11)
R69 — Needs-based staffing with acuity measures
Recommendation: Staffing should be based on service user needs rather than a fixed budget, using daily acuity measures designed specifically for units caring for people with learning disabilities. These should include enhanced supervision requirements, personal care support and therapeutic activities. Service …
No response yet
R31 — Staffing and skills mix review
Recommendation: Health Boards should ensure that the staffing and skills mix is appropriate for each ward, and that it is reviewed in response to increases in the level of activity/patient acuity and dependency in the ward. Where the clinical profile of …
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
R74 — Staffing review in safeguarding investigations
Recommendation: Consideration of staffing (including skill mix as well as total numbers) should be a mandatory part of safeguarding investigations in all settings.
No response yet
R98 — AHP and social care workforce recruitment
Recommendation: The DoH must devise ways to recruit and retain more allied health professionals and social care staff in the community for autistic people and people with learning disabilities.
No response yet
R82 — Risk-based inspection prediction
Recommendation: RQIA should consider developing a risk-based way of predicting which services are in difficulty. It is well known that certain aspects of services tend to be associated with abuse: service users who are vulnerable, who have few communication skills; service …
No response yet
FENN-80 — Ensure adequate staffing by suitably trained personnel in station operations rooms
Recommendation: Station operations rooms shall always be adequately staffed by suitably trained personnel.
Unknown
23 — Quarterly assessment of staffing levels against population needs
Recommendation: The Home Office and contractors operating immigration removal centres must ensure that there is ongoing assessment of staffing levels (at least on a quarterly basis), so that the level of staff present within each centre is appropriate for the size …
Gov response: 6.8.4. Contract requirements across IRC contracted service providers are being reviewed to provide a policy on safe staffing levels and appropriate mitigations where staff capacity is temporarily an issue.
Accepted, fully or in part (not specified)
F163 — Safe staff numbers and skills
Recommendation: The General Medical Council's system of reviewing the acceptability of the provision of training by healthcare providers must include a review of the sufficiency of the numbers and skills of available staff for the provision of training and to ensure …
Gov response: Accepted. The General Medical Council’s standards for training includes (at Domain 8) educational resources and capacity and provides that there must be a suitable ratio of trainers to trainees. The General Medical Council has made …
Accepted
F93 — NHS Litigation Authority Improvement of risk management
Recommendation: The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based guidance and benchmarks where these exist and to demonstrate that …
Gov response: Accepted in principle. As in the response to recommendation 91, the NHS Litigation Authority will move away from assessments against a set of risk management standards to a new outcome focused approach. The new approach …
Accepted in part
F23 — Responsibility for regulating and monitoring compliance
Recommendation: The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations. The standard procedures and practice should include …
Gov response: Accepted. The Department of Health have therefore tasked the National Institute for Health and Care Excellence to set out authoritative, evidence-based guidance on safe staffing. By Summer 2014, the National Institute for Health and Care …
Accepted
25 — Ensure senior manager presence and accessibility to staff
Recommendation: Contractors operating immigration removal centres must ensure that senior managers are regularly present and visible within the immigration removal centre and are accessible to more junior detention staff.
Gov response: 6.8.1. The report findings in relation to contracted service provider staff behaviour and culture were shocking and unacceptable. Significant changes have been implemented to better define operational staffing levels, introduce accredited training, a code of …
Accepted, fully or in part (not specified)
Prevention of Future Deaths reports(162)— showing 50 strongest matches
Mohammed Chaudhury
Concerns: The coroner identified concerns regarding the development and deterioration of pressure sores due to inadequate nursing care, including a failure to turn patients regularly, missing care plans, and inconsistent Waterlow scoring. Additionally, nursing rotas were unavailable, understaffing was reported, and the safety of current staffing levels for high-dependency patients could not be confirmed.
Overdue
Terrance O’Connell
Concerns: A communication breakdown between the care home, district nurses, and out-of-hours GP meant Mr O'Connell was not seen by clinical staff. There was no direct monitoring of his oral input and urinary output, and no clinical assessment for two days.
Response (Gabbandco): • Monkstone House implemented a policy to send patients to A&E if a health professional does not attend within one hour of being called. • The catheter care policy was … (AI summary)
Response: • The Health Board implemented SBAR (Situation, Background, Assessment, Recommendation) message sheets for switchboard staff to record out-of-hours requests for District Nurses in greater detail. • The Clinical Manager for … (AI summary)
Overdue
Henry McQuoid
Concerns: The coroner noted insufficient staffing levels to assist residents with eating, and a high reliance on agency staff. This raised concerns that some residents requiring feeding assistance might not receive it.
Overdue
Barbara White
Concerns: The coroner noted a lack of clinical observations and an incorrect PARS score delaying medical intervention. Concerns also included unescalated insufficient staffing on the surgical unit and communication gaps during handover, affecting subsequent clinical consideration.
Overdue
Wayne Broad
Concerns: The coroner identified a lack of dedicated substance misuse teams for detainees in police custody and for patients in hospitals. Concerns were also raised regarding the alignment of handcuffing policies for seriously ill detainees with ACPO guidance.
Response: • The responsibility for healthcare in police custody suites will transfer from individual police authorities to NHS England. • Healthcare for persons in custody will be commissioned to NHS standards … (AI summary)
Overdue
Pamela Bailey
Concerns: The coroner noted delays in implementing a new door security system for secure wards, insufficient staffing levels on a ward, and the unavailability of a patient's photograph for police during a disappearance.
Overdue
John William Tugwell
Concerns: The coroner noted that a resident identified as a falls risk, with a history of previous falls, was allowed unsupervised access to stairs within the care home.
Overdue
Marjorie Evelyne Keogh
Concerns: The coroner identified a lack of assessment for a resident's suitability for a first-floor room, concerns about staffing levels and manager absence, and conflicting falls and manual handling risk assessments. Additionally, staircase furniture did not meet strength requirements.
Response (My Mil Limited): • The care home stated it completes needs assessments and premises internal area risk assessments for residents, including for upstairs rooms. • The care home stated it uses individualised care … (AI summary)
Response (CQC): • The Care Quality Commission (CQC) stated it is reviewing its approach to registration, informed by the coroner's report. • The CQC plans to undertake checks and seek evidence to … (AI summary)
Responded
Keith Barton
Concerns: The coroner noted a lack of clarity regarding the required supervision level for a speech and language therapy recommendation and insufficient access to external dysphagia awareness training for all staff.
Response (Life Style Care): • The respondent stated it would ensure all Speech and Language Therapist (SALT) recommendations are reviewed by a senior nurse for clarity. • The respondent arranged and completed dysphagia awareness … (AI summary)
Responded
Beryl French
Concerns: Concerns were raised regarding nursing staff's understanding of DNACPR forms and the completeness of information required for them. The report also identified insufficient End of Life Care planning to guide staff in supporting residents to die peacefully and with dignity.
Response (Life Style Care): • Life Style Care Plc has implemented a requirement for a GP-signed DNAR form to be present on a service user's file for it to be effective. • A new … (AI summary)
Responded
Ian Page
Concerns: The coroner noted training needs in communication following patient handover, a lack of falls risk assessment and low bed provision for Mr. Page, and a need to review nursing staff levels.
Overdue
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
John Bird
Concerns: The care home manager did not provide the falls risk assessment at the inquest. The coroner also noted that a carer was unfamiliar with a resident's high falls assessment and care plan, which the manager acknowledged was their responsibility to ensure staff knew.
Overdue
Noreen Porter
Concerns: Care home staff did not perform CPR when the deceased collapsed, and there was no process or procedure in place to ensure resuscitation during an emergency.
Response (Bupa): • Focussed supervisions were carried out with all nursing staff to cover Bupa's policy on CPR and the circumstances in which it must be commenced. • Bupa's policies on resuscitation … (AI summary)
Responded
Alois Piska
Concerns: The coroner identified inadequate staffing levels at Harry Sotnick House, which meant residents in communal areas were not supervised at all times.
Response (Care Uk): • Care UK stated that staffing levels on the day of the incident were appropriate and exceeded industry averages. • Care UK confirmed that staff are deployed based on identified … (AI summary)
Overdue
Jane Robinson
Concerns: Basic patient observations were repeatedly unrecorded, with no senior review to detect shortfalls or written rationale for observation frequency. Additionally, the coroner noted no reporting system for professionals not meeting accepted standards.
Response (University Hospitals of Leicester NHS Trust): • Work has begun to introduce a competency assessment for Health Care Assistants, with completion expected by October 2015. • The Trust is implementing an electronic system for recording patient … (AI summary)
Responded
Rufjan Bibi
Concerns: The coroner noted instances where family found the patient in need of changing with delays in nurse assistance, and questioned a nurse's suggestion of private care. Additionally, there was an unexplained five-hour delay in a consultant review for a patient with a low Glasgow Coma Score.
Response (Barts Health NHS Trust): • The Trust apologised to the family regarding the standard of nursing care, the suggestion of private care, and the delay in consultant review. • Intentional rounding, documentation audits, and … (AI summary)
Responded
John Lowe
Concerns: The coroner noted a belief amongst nursing staff that 1:1 care could only be provided for a patient's mental health needs, rather than for their physical care needs or falls risk.
Overdue
Howell Fisher
Concerns: The report identifies insufficient staffing for a high-risk falls patient, meaning one-to-one nursing was not consistently delivered. There was also a lack of handover material on falls risk between hospitals and no formal risk assessments after successive falls.
Overdue
Alison Draper
Concerns: The coroner identified a lack of policy for staff actions when a patient is not found within a 10-minute observation period. Concerns also noted the practical challenge of one staff member managing hourly checks for multiple patients alongside 10-minute observations.
Overdue
Phyllis Broomhead
Concerns: The coroner noted staff training needs at Lord Hardy Court EMI Residential Home concerning head injury protocols and seeking social worker input. Concerns were also raised regarding the sufficiency and objectivity of initial safeguarding referral screenings and the monitoring of high-risk residents.
Response (Rotherham Borough Council): • Rotherham Borough Council provided a detailed action plan in response to the Regulation 28 report. • The action plan outlined actions already taken by the Council. • The action … (AI summary)
Responded
Doreen England
Concerns: The coroner identified a lack of care plans for high-risk patients, insufficient staff knowledge and training regarding pressure sore prevention, and gaps in ward leadership and medical cover.
Response: • The case has been tabled for discussion at the Quality Surveillance Group. • NHS England is in communication with Birmingham Cross City CCG and will ensure the CQC is … (AI summary)
Overdue
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
Jean Gillespie
Concerns: The coroner identified that a senior care staff member administering medication was unaware of a resident's life-threatening condition and its urgency. Care home records lacked information on the condition, its symptoms, and the purpose of prescribed medication, presenting a risk if replicated.
Response (MMCG): • Senior Care Assistants received further medication training and competency assessments. • Supervisions were completed to reinforce medication management policies and procedures. • A new manager introduced handover sheets and … (AI summary)
Responded
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
Lee Rigby
Concerns: The coroner noted support workers lacked keys to premises, potentially leaving residents unobserved when admitting other staff, and raised concerns regarding the adequacy of staff numbers, risk management procedures, and staff training related to care plans.
Overdue
Leslie Murray
Concerns: Insufficient staff cover for 1:1 patient care on Holdsworth ward, and likely other wards, leads to preventable falls and care deficiencies that may contribute to death.
Overdue
Edith Kirkham
Concerns: The intermediate care ward had inadequate planning, unclear care standards, and insufficient staffing. There was no proper handover from the hospital regarding patient needs, and physiotherapy was significantly delayed.
Overdue
Margaret Metcalfe
Concerns: Staff were not alerted by either Mrs Metcalfe's hand-held buzzer or her specialist bed alarm when she got out of bed, leading to her fall.
Response (Stockton on Tees Borough Council): • Care Assist pagers and charging units were checked, re-labelled, and their charging units relocated for management oversight. • A written procedure was implemented for staff, covering risk assessment, equipment … (AI summary)
Responded
Jane Bell
Concerns: The coroner identifies insufficient arrangements for constant poolside supervision at the hotel, noting concerns that reliance on CCTV monitored by reception staff with other duties and infrequent patrols may not ensure adequate visibility of the pool.
Response (Jane Bell): • The hotel implemented constant poolside supervision, with trained staff patrolling the poolside and another trained staff member monitoring CCTV from reception. • The pool's depth was reduced to 1.4m, … (AI summary)
Responded
Pamela Thurston
Concerns: The coroner identified insufficient direct supervision during mealtimes for a resident with dementia, who choked after being given toast following a 17-hour period without food. Her care plan was also not updated despite a prior related incident.
Response (Thurston): • The organisation issued a memorandum to all Home Managers, Regional Managers, and Head of Operations outlining requirements for timely meals, choking risk assessments, and supervision of at-risk service users … (AI summary)
Overdue
Lillian Hursell
Concerns: Bedrail mechanisms at the care home sometimes did not fully engage, creating a fall risk. After a significant fall, staff moved a patient without fully assessing for head and spinal trauma.
Response (Hursell): • Programmes of re-training in first aid, moving and handling, and health and safety were commenced, to be completed by 1 June 2016. • A system of bedrail audits was … (AI summary)
Responded
Freda Cordy
Concerns: The coroner noted Mrs Cordy was placed in a care home with 2-hourly checks despite needing constant supervision. No specific falls risk assessment was undertaken despite a falls history, and only a floor mattress was provided for prevention.
Overdue
Olive Wilmott
Concerns: The coroner noted a lack of effective investigation or safeguarding referral regarding possible pushing, despite medical records, and insufficient evidence of mandated 15-minute observations. There were also insufficient night staff to meet residents' needs on the dementia unit.
Overdue
Margaret Gleeson
Concerns: The coroner noted that weekend on-call staffing levels were insufficient for the workload, potentially impacting patient care, and suggested a review. There were also inaccuracies in MEWS tool scoring, indicating a need for refresher training as its use was not clearly understood.
Response (Wrighton Wigan and Leigh NHS Trust): • The Surgical Division allocated a middle grade surgeon to conduct weekend ward rounds for elective patients, and the Trust is recruiting two clinical fellows. • The Trust provided extensive … (AI summary)
Responded
Alan Stead
Concerns: The coroner identified delays in taking and testing blood samples from prisoners at HMP Dovegate, asking what actions can be taken to improve this situation at the prison and potentially others.
Response (Care UK): • A phlebotomy training programme for all nurses and healthcare assistants was introduced at HMP Dovegate in December 2015. • The phlebotomy training programme was completed, and staff were deemed … (AI summary)
Responded
Daphne McCorkle
Concerns: The coroner identified a gap in night-time care provision for patients requiring frequent turning to prevent pressure sores, as neither Lewisham District Nurses nor commissioned agency carers provide visits at night.
Response (D McCorkle): • The CCG stated it would take steps to improve the risk assessment of patients discharged from hospital with pressure ulcers into community care. • The CCG confirmed it had … (AI summary)
Overdue
Edwina Moses
Concerns: The coroner identified a poor system for requesting and securing additional nursing cover for one-to-one patient support, leading to staff confusion and frequent unavailability of help. This raised concerns about staffing levels and staff capacity to safely care for patients.
Response: • The Princess of Wales Hospital Managed Unit reviewed its process for enhanced observation, including the standard of completion of risk assessments. • A process to monitor staffing levels across … (AI summary)
Overdue
Jean McHale
Concerns: The coroner noted concerns that untreated pressure ulcers can lead to severe complications in the elderly, identifying an insufficient number of Tissue Viability Nurses in both community and hospital settings. An urgent review was deemed necessary to address these resource gaps.
Response (SEPT): • A service review of the Tissue Viability Nurse (TVN) service was undertaken. • The Trust confirmed clear pathways are in place for timely referrals and stated it had increased … (AI summary)
Overdue
Jennifer Clark
Concerns: The coroner notes that the Neonatal Unit at Watford General Hospital is inadequate for the high number of annual births, and a proposal for its expansion was rejected, posing a risk to babies' lives.
Response (West Hertfordshire Hospitals NHS Trust): • The Trust implemented a Neonatal Unit Admissions and Escalation Policy in 2015 to manage unit capacity. • The Trust Board approved a redevelopment plan for hospital estates and facilities, … (AI summary)
Responded
Etheline De-Gale
Concerns: The care plan was too vague to guide carers, who also lacked training on how to undertake risk assessments. Insufficient staffing levels compromised resident safety, potentially leading to paramedic recommendations being ignored.
Response (Response Ambassador House Home): • Care plans will be updated to stipulate that residents must not be left unattended when bedrails are lowered for assistance. • Staff have been instructed to carry gloves at … (AI summary)
Responded
Daphne Cherry
Concerns: The coroner raises concerns about the ability of care home staff to identify when to escalate medical concerns and when a medical review should be sought.
Response (Care UK): • Home managers, deputy managers, and unit leaders have undergone training in 'Early recognition of the sick and deteriorating patient'. • Unit leaders are tasked with cascading training principles, including … (AI summary)
Responded
Annette Krasinsky-Lloyd
Concerns: The coroner identified inadequate supervision for the SHO, delays in consultant engagement, obtaining test results, and administering critical treatments. There were also concerns regarding insufficient patient monitoring in the A&E department.
Overdue
Steven Amos
Concerns: The coroner noted concerns regarding the appropriate escalation of care for patients who acutely deteriorate during night shifts over weekend periods.
Overdue
Janet Muller
Concerns: The coroner noted incomplete nursing records, handovers, and care plans, with audits failing to identify these deficiencies. Concerns were also raised about patients detained under the Mental Health Act being able to abscond due to insufficient security and inadequate staffing levels.
Overdue
Joseph Tarnowski
Concerns: The coroner noted that the resident may not have been aware his call-bell was portable or able to move it due to mobility issues, and the care home had not considered introducing wearable call bells.
Response (Hillbrook Grange): • Hillbrook Grange provided residents with call bells designed to be worn around their necks. • The board of directors approved this recommendation, and the system was implemented within a … (AI summary)
Responded
Beryl Goode
Concerns: The coroner noted that night shift staff did not consider a head injury as the cause of the deceased's confusion and lacked training to identify or exclude head injuries in residents, which could impact future diagnoses.
Overdue
Helen Cannon
Concerns: Emergency responders did not seek medical assistance for a patient with a pelvic fracture that led to internal haemorrhage, contrary to good practice. A subsequent investigation was flawed, failing to address inaccuracies in a risk assessment checklist and a responder's understanding of their signature.
Overdue
Select committee recommendations(27)
#47 —
Recommendation: Many of these pressures on the social care sector—such as funding and workforce— are longstanding and must be resolved urgently. Pressures on the social care workforce are likely to be compounded this autumn by the mandate that people working in …
Response attribution not verified
#47 —
Recommendation: Many of these pressures on the social care sector—such as funding and workforce— are longstanding and must be resolved urgently. Pressures on the social care workforce are likely to be compounded this autumn by the mandate that people working in …
Response attribution not verified
#19 —
Recommendation: The Department told us numbers in the social care workforce were going in the right direction and that domiciliary care and care home workforces were expanding.70 However, written evidence sent to us by the National Care Forum highlights that, as …
Response attribution not verified
#18 —
Recommendation: The social care workforce is in a similarly precarious position, against a wider backdrop of declining local authority resources.64 Despite the Department’s assurances that “the numbers are moving in the right direction”, vacancies in social care have been on an …
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
#1 —
Recommendation: The covid-19 pandemic has had a severe impact on adult social care. People have received less care and often care workers have been compelled to deliver only the basics. More people are going without care and many people’s needs are …
Response attribution not verified
#3 —
Recommendation: The Department has started taking some action to address workforce challenges in social care, but vacancies have increased by 50% in the last year and the number of people working in social care fell in 2021/22 for the first time …
Response attribution not verified
#19 —
Recommendation: The COVID-19 pandemic has had devastating consequences both for vulnerable people using social care, and for the committed professional workforce that provide that care. These challenges have been exacerbated by long-standing funding and workforce issues which need to be recognised …
Response attribution not verified
#16 —
Recommendation: The Home Office should—in partnership with the Department of Health and Social Care—conduct a full assessment of the potential impact of its planned changes to routes to settlement on the adult social care workforce, and on the stability of the …
Response status not verified
#15 —
Recommendation: It is extremely hard to predict what impact these changes will have on the social care workforce. Given the level of overseas recruitment that has taken place, decisions about routes to settlement for social care workers are likely to affect …
Response status not verified
#14 —
Recommendation: If the Government implements a 15-year qualifying period for adult social care workers, we recommend that it takes urgent action to support decent pay and conditions for this group. The Home Office should set out in response to this report …
Response status not verified
#55 — Social care staff shortages severely impact the provision of good-quality care.
Recommendation: We have heard evidence that staff shortages are having an impact on the ability of social care staff to provide good-quality care to the people they support. Lara Bywater told us that in the 20 years she has been running …
Response attribution not verified
#20 —
Recommendation: We believe that the starting point for the social care funding increase must be an additional £7bn per year by 2023–24 to cover demographic changes, uplift staff pay in line with the National Minimum Wage and to protect people who …
Response attribution not verified
#2 —
Recommendation: It is clear from the evidence we have heard that funding shortfalls are having a serious negative impact on the lives of those who use the social care system, as well impacting the pay levels of the workforce and threatening …
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
#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
#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
#22 — Private providers significantly dominate the residential care market, owning 84% of all settings.
Recommendation: In 2024–25, 84% of residential care settings registered with Ofsted, including supported accommodation and children’s homes, were owned by private providers.57 The Department told us this accounts for 74% of residential care places, because privately-owned homes tend to offer fewer …
Response attribution not verified
#14 —
Recommendation: The Department told us that its initiatives to increase the supply of nurses into the NHS should benefit social care as both sectors have the same entry route. However, our Committee remains concerned about potential barriers to moving between sectors …
Response attribution not verified
#11 —
Recommendation: Nursing students cover both health and social care in their training and decide which sector to work in after they graduate. This means that social care providers recruit from the same overall pool of nurses as the NHS. The Department …
Response attribution not verified
#4 —
Recommendation: The coronavirus pandemic has highlighted and exacerbated pre-existing systemic problems in the social care system, including urgent need for: a more sustainable funding solution; resolution of workforce issues, including low pay, poor progression and high staff turnover; and much closer …
Response attribution not verified
#181 —
Recommendation: The Health and Social Care Committee’s Reports on social care and the delivery of core NHS and care services during the pandemic also highlighted the impact of a lack of testing for social care staff in the initial wave of …
Response attribution not verified
#181 —
Recommendation: The Health and Social Care Committee’s Reports on social care and the delivery of core NHS and care services during the pandemic also highlighted the impact of a lack of testing for social care staff in the initial wave of …
Response attribution not verified
#6 —
Recommendation: As emphasised by Alzheimer’s Society and other key stakeholders, social care reform must be “rooted in the recognition of what good quality care looks like” and 20 Supporting people with dementia and their carers create a system where people with …
Response status not verified
#17 — NHS Providers warn Hospital 2.0's 95% bed occupancy assumption is unsustainable and unsafe.
Recommendation: In written evidence to us, NHS Providers advised that the standardised design had to be sufficiently future-proofed to handle changes in demand, practice and public expectations. It was concerned that future planned bed occupancy levels should be safe, and warned …
Response attribution not verified
#60 — Publish a fully costed plan for funding Level 5 diplomas for care home managers.
Recommendation: It is clear that some care home managers lack the training and support they need to stay in post. We welcome the Government’s commitment to fund Level 5 diplomas for those who need them, and we urge the Government to …
Response attribution not verified
#12 —
Recommendation: The Chief Nursing Officer of NHSE&I emphasised how the COVID-19 pandemic has illustrated the importance of social care and the value of better integration between health and social care. She commented that “if anything good can come out of it …
Response attribution not verified
CQC inspection actions(90)— showing 50 strongest matches
Westmorland General Hospital
The service must ensure they deploy sufficient suitably competent and experienced staff and ensure all staff receive appropriate skills and drills training and professional development to enable them to maintain competency given the low numbers of deliveries.
Must Do
Westmorland General Hospital
The service must ensure that women presenting in labour have immediate access to suitable qualified and skilled midwifery staff.
Must Do
Westmorland General Hospital
The service must ensure there are sufficient maternity staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment.
Must Do
North Devon District Hospital
The service should review use of acuity tools to ensure accurate monitoring and response to staffing pressures.
Should Do
UHBW Bristol Campus
The service should ensure that 'red flag' midwifery staffing incidents are monitored in line with national guidance.
Should Do
UHBW Bristol Campus
The service must ensure that 'red flag' midwifery staffing incidents are monitored effectively, including delays to induction of labour, in line with national guidance.
Must Do
Chy Byghan Residential Home
The provider must ensure people who use services are protected against the risks associated with not having sufficient numbers of suitably qualified, competent, skilled and experienced persons to meet the service requirements.
Must Do
Ambleside - Luton
The provider must ensure that there are sufficient numbers of suitably qualified, skilled and experienced staff.
Must Do
Valewood House Nursing Home
There were insufficient numbers of suitably qualified, skilled and experienced staff to safeguard people’s health, safety and welfare.
Must Do
Pennsylvania House
The provider must ensure people who use services are protected against the risks of receiving unsafe or inappropriate care by basing staffing levels at night on people's assessed needs.
Must Do
Laurel Lodge Care Home
The provider must ensure that there are sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of people using the service.
Must Do
Highfield House Residential Home
The provider must ensure appropriate staffing.
Must Do
Chiltern View
The provider must ensure there are enough staff deployed throughout the home to ensure people's care and support needs are met safely.
Must Do
Cary Lodge
There were not sufficient numbers of skilled staff deployed to keep people safe. 18(1)(2)(a)
Must Do
Benthorn Lodge
The registered person has failed to ensure that sufficient numbers of suitably qualified, competent, skilled and experienced persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.
Must Do
Walmer Lodge Residential Home
Sufficient numbers of suitably qualified, competent, skilled and experienced persons were not deployed. 18.1
Must Do
The Peter Gidney Neurodisability Centre
There was a lack of suitably qualified, experienced and skilled staff to meet people's needs.
Must Do
The Moat House
Sufficient numbers of staff were not always available to meet people's care and support needs.
Must Do
The Gateway
There were insufficient numbers of suitably qualified and experienced staff to consistently meet the needs of people who used the service.
Must Do
Slate House Residential Home
The provider must ensure that at all times there are sufficient numbers of suitably qualified, skilled and experienced staff.
Must Do
Shenstone Hall Nursing Home
The provider must ensure staffing levels are continuously reviewed and adapted based on people’s assessed needs to ensure they are sufficient to meet people’s needs at all times.
Must Do
Robin Hood House
The provider had failed to ensure there were sufficient numbers of suitably trained staff deployed at all times to meet people's needs safely.
Must Do
Palm Court Nursing Home
We recommend that the service considers using a tool to determine suitable staffing levels and reviews staffing levels regularly to ensure people receive safe care and support at all times.
Should Do
Newland House
The provider did not have a system in place to accurately determine the number of staff required.
Must Do
Newland House
The provider did not ensure sufficient numbers of suitably qualified staff were deployed to fully meet people's care needs. This had impacted on staff's ability to provide care in line with the fundamental standards of the Health and Social Care …
Must Do
Lincoln Lodge Residential Home for the Elderly
staffing levels should be reviewed.
Should Do
Keb House Residential Home
The registered provider failed to ensure sufficient numbers of suitably qualified, competent and skilled staff were deployed.
Must Do
Karenza Care Home
The provider had failed to ensure there were always adequate numbers of staff to meet people's needs.
Must Do
Holmesley Nursing Home
We recommend the provider keep staffing levels, people's dependency levels and the deployment of staff at the service under review.
Should Do
Holly House Residential Care Home
The provider must ensure there are sufficient staff to support people in a way that ensures their continued safety.
Must Do
Holly Court Care Home
We recommend a dependency tool is used to help determine appropriate staffing levels, based on the number of people living in the home and their changing needs.
Should Do
Highcliffe House Nursing Home
The manager agreed to reassess people's needs and to make any necessary changes to ensure there were sufficient staff.
Should Do
Fremington Manor Nursing and Residential Home
The provider had failed to ensure sufficient numbers of staff were consistently deployed to meet people's needs.
Must Do
Beech House - Basildon
The provider must ensure there are always enough staff on shift.
Must Do
Ashington Gardens
Regulation 18 HSCA RA Regulations 2014 Staffing
Must Do
We (Always) Care Under One Roof Limited
The provider must ensure sufficient staff are deployed.
Must Do
Walnut Villa
People were at risk of their needs not being met because there were insufficient staff provided and at times staff were not present in the home. Staff did not always have the relevant skills to meet people's care needs safely. …
Must Do
The Homestead (Crowthorne) Limited
The registered person failed to consistently ensure that sufficient numbers of staff are deployed to meet people's needs.
Must Do
Stepping Out
Staffing levels were not sufficient to ensure the safety of staff and service users.
Must Do
St Paul's Lodge
The registered person must ensure suitably qualified, skilled and experienced persons are deployed to meet people’s needs.
Must Do
Redcot Lodge Residential Care Home
The provider must ensure sufficient numbers of suitably competent and experienced staff are deployed.
Must Do
Precious Nursing & Residential Home
The provider must ensure people receive safe care by deploying sufficient trained staff to meet their needs.
Must Do
Park Grange Care Home
We concluded staffing levels and deployment of staff were not maintained to ensure people were not at risk of their care needs been met.
Must Do
Oaklands Care Home
The provider must ensure there are sufficient numbers of suitably skilled and experienced staff deployed at all times.
Must Do
JDK Limited (Glenholme Care)
There were not enough staff employed to deliver the service which was needed to meet people’s needs
Must Do
Elsinor Residential Home
Comply with Regulation 18 (Staffing)
Must 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
Benthorn Lodge
The provider must ensure that staffing levels are sufficient to meet people's care and support needs safely.
Must Do
Attwood's Manor Care Home
The provider must ensure that staff are effectively deployed to meet people's needs.
Must Do
Ashmore House
The provider must ensure sufficient numbers of suitably qualified, skilled and experienced staff are deployed.
Must Do
PPO death in custody recommendations(6)
The Head of Healthcare and Greater Manchester Mental Health Services
The Head of Healthcare and Greater Manchester Mental Health Services should consider what additional support can be put in place to address staffing shortages at Garth and consider how they can reasonably deliver a meaningful healthcare resource.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies in line with Prison Service Instruction (PSI) 03/2013. In particular, where there are serious concerns about the health of a prisoner, …
The Director
The Director should remind staff of their responsibilities in a medical emergency, including that they should radio the correct medical emergency code immediately.
The Governor of HMP Sudbury
The Governor should ensure that, in line with National Instructions, an ambulance is called immediately in an emergency medical situation and that ambulances have speedy access to prisoners in all parts of the prison.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, in particular that staff efficiently communicate the nature of a medical emergency using the appropriate code.
The Governor
The Governor should ensure that adequate supervision and support arrangements are in place for RSAs and issues they raise are discussed at the relevant social care MDT meeting.
IMB annual reports(15)
Warren Hill (2022)
Warren Hill maintained a safe environment despite Covid-19 constraints, effectively managing outbreaks and promoting positive staff-prisoner interactions. The IMB commends the prison's efforts in harmonising regimes and establishing on-site approved premises. However, persistent issues with food provision, the suspension of the ROTL pilot, and challenges related to prisoner property and in-cell telephony remain significant concerns, along with the impact of recent parole changes on prisoner morale and progression.
PRISON
Key concerns
The Verne (2022)
HMP The Verne, an adult training prison for men convicted of sexual offences, has largely restored its 'core day' regime following COVID-19, maintaining a safe environment with good staff-prisoner relationships and high-quality healthcare. However, the report highlights critical issues, particularly regarding the inadequate 24-hour social care and onsite hospital provision for its growing elderly and frail population. Significant understaffing in the Offender Management Unit continues to undermine resettlement efforts for the substantial number of prisoners released directly from this training prison, alongside concerns about low prisoner pay and a third of the population lacking purposeful activity.
PRISON
Key concerns
Low Newton (2023)
HMP/YOI Low Newton is a well-managed women's prison that successfully adapted its regime post-Covid. While praised for its safe environment, estate improvements, and dedicated staff, it is significantly hampered by staff shortages, impacting regime delivery and key worker scheme consistency. The Board highlights concerns regarding funding for essential facilities, the management of complex prisoners, and the need for improved transport arrangements and oversight of disciplinary processes.
PRISON
Key concerns
Feltham (2023)
Feltham, comprising a YOI (A side) and a Cat C prison (B side), faced significant challenges in the reporting year ending August 2023, primarily due to severe staff shortages impacting regime delivery, time out of cell, and purposeful activity. While staff were commended for their dedication, these shortages led to increased incidents on A side and curtailed essential services and rehabilitative programs across both sides. Key concerns also included the inadequate education provision for separated young people, safety in communal showers on B side, and the ongoing issue of lost prisoner property.
PRISON
Key concerns
Altcourse (2021)
HMP Altcourse was judged a safe prison during the reporting year, demonstrating low levels of self-harm and violence despite pandemic restrictions. The Board noted significant improvements in food quality and strong staff-prisoner relationships. Key concerns include the persistent delays in transferring seriously mentally ill prisoners, issues with property, and the uncertain future and low morale of the resettlement service following a contract change.
PRISON
Key concerns
Bristol (2021)
HMP Bristol successfully managed Covid-19, implementing strong infection control and a good vaccination programme. The prison saw significant improvements in accommodation and the general environment, alongside a reduction in self-harm and violence. However, the Board remains concerned about inconsistent key work delivery, staffing shortfalls, persistent issues with disability access, and the appropriate placement of vulnerable prisoners.
PRISON
Key concerns
Brixton (2021)
The reporting year at HMP Brixton was dominated by COVID-19, leading to severe restrictions on the prison regime, impacting prisoners' mental health and resettlement opportunities. Despite significant efforts by staff and healthcare to maintain services and well-being, concerns persisted regarding the suitability of the offender flow system, inadequate accommodation for older prisoners, and a lack of D-category prison places. While self-harm incidents slightly decreased, assaults on staff increased, and substance misuse remained a challenge, with the Board commending positive aspects like food quality, staff commitment, and progress in education.
PRISON
Key concerns
Preston (2023)
HMP Preston, a Category B reception prison, continues to face challenges common to Victorian establishments, including chronic overcrowding (670 population vs. 433 CNA). Staffing levels are effectively low due to sickness and training, impacting key worker provision and regime. While some areas like self-harm incidents have reduced and in-cell phones installed, significant concerns remain regarding reception facilities, prisoner property management, and adequate budget for essential equipment. The Board made several recommendations to address these and other issues related to regime, family engagement, and staffing.
PRISON
Key concerns
New Hall (2023)
HMP/YOI New Hall reported a population of 335 and an operational capacity of 381 for the year ending February 2023. The prison saw a significant reduction in self-harm incidents (609, down from 965) and use of force, alongside a good HMIP report and positive staff-prisoner relationships. Key concerns include underfunded trainee officer allocations, slow recruitment checks, the need to address OFSTED recommendations, and frustrating waiting lists for prisoner jobs.
PRISON
Key concerns
North Sea Camp (2024)
HMP North Sea Camp generally provides a safe and humane environment, with a strong emphasis on humane treatment and a wide range of release preparation programs. Positive developments include improved facilities management, a proactive safer community team, and good healthcare services that receive positive feedback from prisoners. Key concerns include persistent delays in offender management paperwork, the unresolved situation for IPP prisoners, and poor accommodation standards with no plans for replacement or conversion of dormitories. Additionally, issues with prisoner property transfers, lack of on-site end-of-life care, and difficulties for disabled prisoners accessing resettlement opportunities remain.
PRISON
Key concerns
Doncaster (2025)
HMP Doncaster was rated the top local prison nationally, demonstrating strong performance in areas like refurbishment and support services. Despite an improved regime and full staffing, significant challenges persist, including increased prisoner violence due to overcrowding, and persistent, prolonged delays in mental health transfers. The IMB highlights critical issues such as national probation staffing deficits, property management concerns, and unanswered cell bells, calling for urgent attention from government and prison management.
PRISON
Key concerns
Bristol (2020)
HMP Bristol, a Category B local prison, navigated the reporting year (August 2019 – July 2020) under significant COVID-19 restrictions, which impacted the daily regime but also led to a more settled environment and improved staff morale. Despite efforts, safety ratings remained low, with high levels of self-harm, violence, and increased use of force incidents. Challenges persisted with delayed mental health transfers, unsuitable Victorian accommodation for disabled prisoners, and resource issues affecting key work and healthcare.
PRISON
Key concerns
Highpoint (2021)
HMP Highpoint is a male Category C training and resettlement prison. The reporting year saw a positive reduction in self-harm and violence, with staff commended for humane Covid management. Key concerns include persistent issues with property transfers, under-resourcing in contracted services like mental health and education, poor maintenance by GFSL, and the ongoing security vulnerability from unrepaired netting.
PRISON
Key concerns
Humber (2024)
HMP Humber, a Category C resettlement prison, experienced significant challenges in 2024 due to high prisoner turnover and population pressures. While the Board commends management's efforts in maintaining safety and improving regime stability, issues persist concerning property loss, inadequate purposeful activity, and cell sharing. Healthcare provision is improving but faces space and recruitment challenges, while key worker schemes are compromised by staffing shortages.
PRISON
Key concerns
Cardiff IMB (2025)
Overall, HMP Cardiff has seen positive developments in safety, with significant reductions in self-harm and use of force incidents, and successful digital platform implementation. However, the prison continues to grapple with severe staffing shortages, particularly in healthcare, and the physical estate remains in poor condition, affecting prisoners with mobility issues and access to basic amenities. Concerns persist regarding delays in mental health transfers, lack of secure medication storage, and the underperformance of the key worker scheme.
PRISON
Key concerns
IMB individual recommendations(3)
Springhill (2023)
OMU staffing problems being addressed to enable it to again achieve its 8-12 week targets for sentence plan and offender assessment system (OASys) processes to be completed (7.3.5 and 7.3.7 and 7.3.8).
Governor / Director
Channings Wood (2025)
Can HMPPS confirm what actions are to be taken to ensure staffing levels at HMP Channings Wood are restored and maintained?
HMPPS
Implemented
Berwyn (2022)
As the prison population ages, the Board would like to see training for staff on recognising and dealing with dementia and other age-related needs.
Governor / Director
Health investigations(11)
Independent investigation: Jenny Morrison (s/w), Balham,S London (1998) — Rec 4
The London Borough of Wandsworth urgently review the staffing levels, safety provisions, procedures for supervising medication, and day activity programmes in the residential mental health care homes within the Borough.
london
Independent investigation: Jonathan Newby, Oxford (1993) — Rec 6.12
Health authorities should offer to appoint a qualified mental health professional as a sessional consultant or adviser to residential care homes and hostels which house significant proportions of people with severe mental illness.
south_east
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R34
The trust should undertake a review of the dependency needs of the clients on Conolly ward and the appropriate staffing to meet those needs. The review should be undertaken collaboratively with the staff on the ward and any changes made explained fully to them. The review should take account of …
london
Independent investigation: Jenny Bryant, Consett — Rec 5
This case identified a lack of knowledge about the facility within the local authority to fast track a request for adhoc additional funding for additional staffing cover where interventions such as one: one observation for a care home resident is required for a period of time to maintain a safe …
north_east_yorkshire
An independent investigation into the care and treatment of mental … — Rec 4
The Trust should assure themselves and commissioners that arrangements are in place to provide appropriate medical cover on the acute adult in-patient wards to ensure medical oversight and continuity of care.
Greater Manchester Mental Health NHS Foundation Trust
north_west
Accepted
Independent investigation into the care and treatment of MR: Published … — Rec 5
This case identified a lack of knowledge about the facility within the local authority to fast track a request for adhoc additional funding for additional staffing cover where interventions such as one: one observation for a care home resident is required for a period of time to maintain a safe …
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation: Jonathan Newby, Oxford (1993) — Rec 6.14
Health authorities should ensure that they purchase sufficient high care accommodation to meet needs in their areas, including the needs of those people who are currently housed in hostels where the staffing numbers and skills cannot adequate care. (This is a current Department of Health priority, but one where they …
south_east
An independent investigation into the care and treatment of MS: … — Rec 3
In order to overcome the divide between mental and physical healthcare, liaison psychiatry services should be fully integrated into general hospitals. The structure and staffing of the liaison psychiatry service should be based on the clinical demand, both within working hours, and out-of-hours, so that they can participate as part …
north_east_yorkshire
An independent investigation into the care and treatment of Mr … — Rec 1
The one issue arising from this case that cannot be allowed to continue is the lone working situation for adult and children’s emergency duty teams. How these teams can be co-located with other out of hours mental health teams must be explored. It simply does not make logical sense for …
north_west
An independent investigation into the care and treatment of Harry … — Rec 21
We recommend that LTHT offer to meet with the families to address their unanswered questions and discuss changes that have been made following this incident, including: how staffing levels are calculated and delivered on medical wards; and, how safeguarding is practised and how the safety and security of …
Leeds and York Partnership NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Harry … — Rec 12
We recommend that LTHT conduct a risk assessment when vulnerable patients may be in a bay with patients who are aggressive or agitated. We further recommend that LTHT take steps to ensure that where patients are inappropriately placed together that additional staffing is secured to maintain their safety.
Leeds and York Partnership NHS Foundation Trust
north_east_yorkshire
Scottish Fatal Accident Inquiries(2)
Marion Helen Adam Ramsay, John Rodgers Cowe and Isabella McGregor
Consideration should be given to the introduction of Consultant Geriatricians as raised in the testimony of Doctor Harrington in accordance with the models used elsewhere in the United Kingdom.
Dec 2007
George Jamieson Fairlie
In terms of Section 6(1)(e) 1. Care Homes which offer a dedicated dementia Unit should ensure that trained nursing staff and staff who work as care assistants have training in the treatment of patients with dementia. 2. All nursing and care staff employed in Care Homes should be given a proper induction at the commencement of their employment and unqualified …
Jun 2006
Detention investigations(5)
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R31
G4S and the SMT should ensure that the welfare team is adequately staffed at all times. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R6
The SMT should urgently ensure that Brook House is fully staffed. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R7
G4S managers should undertake a comprehensive review of matters affecting staff retention at Brook House including remuneration, shift patterns and working hours and G4S needs to develop plans to address the matters arising from such a review. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R32
G4S and the SMT should ensure that the welfare team has the technological and administrative support it needs. (To be completed within 6 months)
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 13
the question of staffing levels be reviewed to assess if future contracts should contain more prescriptive requirements in relation to staff numbers.
Immigration Detention
Independent reviews(3)
Narey Review of Children's Residential Care — Rec 4
I recommend that providers examine their staff attendance systems to ensure they are as effective as possible in meeting the needs of children. And commissioners, when placing children, should look closely at the numbers of staff on duty at key times of the day.
Other
Tickell Review of the EYFS — Rec 32
I recommend that the Government research as a matter of importance the ratios currently used in reception classes. This should include the use of support staff and identifying and sustaining current good practice if needed.
Education
Tickell Review of the EYFS — Rec 33
I recommend that the Government should take the opportunity when redrafting the EYFS to reflect the parity between the ratio requirements for independent and maintained schools which has been in place since 2009.
Education
PHSO casework decisions(4)
P-002934 — Frimley Health NHS Foundation Trust
Mrs K complained about various aspects of her mother's care including delayed enema, delayed UTI diagnosis, insufficient mobilisation, incorrect Parkinson's medication times, and unsafe discharge.
NHS in England
Sep 2024
P-003012 — St George's University Hospitals NHS Foundation Trust
Miss P complained the Trust inappropriately kept her mother in hospital, failed to provide adequate hydration/nutrition and skin care. She also alleged inadequate family updates and denied visits for her mother with dementia.
NHS in England
Upheld
Oct 2024
P-003412 — Derbyshire Community Health Services NHS Foundation Trust
Mrs J alleged poor care from multiple trusts regarding medication, fluid management, missed visits, incorrect triage, and inadequate assessment, which she believed contributed to her mother's death.
NHS in England
Not Upheld
Mar 2025
P-004682 — A practice in the Leeds area
Mrs A complained her father, Mr R, received inadequate care from the Practice and Trust, including a lack of face-to-face consultation and misdiagnosis, leading to his suffering and death.
NHS in England
Jan 2026
LGO / SPSO decisions(407)
21-018-287 — Ideal Carehomes (Number One) Limited
Summary: Mr F complained that the care provider failed to provide proper care to his late mother, Mrs J, prior to her death. We found the care provider’s actions caused injustice to Mrs J and her family. The care provider should waive some of the fees to redress this injustice.
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
23-020-780 — Willow Tower Opco 1 Limited
Summary: We will not investigate this complaint about adult social care at the end of life. The Care Provider failed to treat its resident with dignity and respect following death. The Care Provider has taken action to improve service and apologised to the family for their distress pursuing a complaint. …
LGO (Local Government & …
Adult Care Services
May 2024
NIPSO-16874 — Belfast Health and Social Care Trust
The Ombudsman has found that the Belfast Health and Social Care Trust made a concerted attempt to resolve a complainant’s concerns about the care and treatment provided to her father while he was the resident of a Belfast nursing home.
NIPSO (NI Public Service…
Health & Social Care
Mar 2018
25-012-341 — Bupa Care Homes (GL) Limited
Summary: We will not investigate this complaint about the care and support provided to the complainant’s husband during a respite placement in a care home. The Care Provider agreed to resolve the complaint early by providing a proportionate remedy.
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
PSOW-202104529 — A Care Home
Mr X complained about aspects of care provided to his late father Mr Z, by the Care Home between April 2020 and May 2021. The Ombudsman found that there was no failure to consider the interaction between trazadone (an antidepressant) and lamotrigine (epilepsy medication) and that it was, ultimately the …
PSOW (Public Services Om…
Upheld
Jun 2023
PSOW-202202308 — A Care Home
Mrs A complained about the care and treatment that her late mother, Mrs B, received during the final weeks of her life while she was a resident in a care home in the area of Betsi Cadwaladr University Health Board. Mrs A complained that the Care Home failed to appropriately …
PSOW (Public Services Om…
Upheld
Jan 2024
21-011-179 — Caring Homes Healthcare Group Limited
Summary: We will not investigate this complaint about the quality of residential care and the Care Provider’s response when Miss X raised concerns.
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-012-003 — Kent County Council
Summary: We will not investigate this complaint about the Council’s actions regarding Mrs X’s father’s care needs. This is because it is unlikely we would find fault with the actions of the Council. The Council has also take action to refund care charges to cover an apparent deficit in care …
LGO (Local Government & …
Adult Care Services
Jan 2022
21-000-792 — Porthaven Care Homes No 3 Limited
Summary: Mr X complained Porthaven Care Homes No 3 Limited (the Care Provider) failed to provide adequate care to his wife, Mrs X during her respite stay for ten nights in the autumn of 2020. We found the Care Provider failed to identify an illness Mrs X was suffering from …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-000-200a — Amberley Lodge Care Home (21 000 200a)
Summary: We found fault by a care home acting on behalf of the Council regarding the care it provided to Mr X, an elderly man with complex care needs. We found the care home failed to support Mr X and his wife, Mrs X, to make an informed choice about …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-015-937 — Buckinghamshire Council
Summary: We will not investigate this complaint about the Council’s failure to place Mrs Y in a care home closer to Mr X. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. There is nothing further we …
LGO (Local Government & …
Adult Care Services
Mar 2022
21-004-728 — Care UK Community Partnerships Limited
Summary: There is no evidence of proper oral care for Mr X. Mr X incurred dental fees as a consequence which the care provider has reimbursed. There was poor maintenance of some fluid and hygiene records although their absence is mitigated by the detail in the daily records. Beyond the …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-005-332 — Fridhem Rest Home Limited
Summary: Mrs B complained about the care Mrs C received during the last few months of her life. She also complained about restrictions on visiting arrangements for the family. We found fault with some of the personal care Fridhem failed to provide. Fridhem apologised to Mrs B and her family …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-015-353 — Nottingham City Council
Summary: We will not investigate this complaint about jewellery that went missing when Mrs X was a resident in a care home. That is because there are other bodies better placed to deal with the matter and further investigation would not lead to a different outcome.
LGO (Local Government & …
Adult Care Services
Mar 2022
21-001-178 — Salveo Care Ltd
Summary: Mrs X complained about the care given to her late mother by the Care Provider and that she did not have a face-to-face visit with her before she passed away. We find the Care Provider’s management of her mother’s weight loss, how it told Mrs X of her death …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-007-659 — Cumbria County Council
Summary: Mrs X complained about the level of care provided to her mother, Ms Y, in the last few days of her life by the care home. She also complained about the clearing of Ms Y’s room and the way her belongings were handled. There were failings in the care …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-018-066 — Saima Raja AKA Braemar Care Centre
Summary: We will not investigate this complaint about the Care Provider refusing to issue a refund. This is because the Care Provider has now issued the refund. This remedies the claimed injustice and an investigation could not achieve anything more.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
22-000-089 — Blanchworth Care Homes Limited
Summary: We will not investigate this complaint about missing items belonging to the complainant’s deceased mother. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. An investigation would be unlikely to add anything to the Care Provider’s …
LGO (Local Government & …
Adult Care Services
May 2022
21-018-231 — Four Seasons Mickleton Limited
Summary: We will not investigate this complaint about the residential care received by the complainant’s now deceased mother. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate.
LGO (Local Government & …
Adult Care Services
May 2022
21-002-687 — Bournemouth, Christchurch and Poole Council
Summary: The Council commissioned Mr Y’s care so it is at fault for the failings in that care. It is also at fault for the way it dealt with Ms X’s complaint about this.
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-013-890 — West Berkshire Council
Summary: The Council’s complaint responses should have explained the circumstances of Mrs Y’s fall in a care home it commissioned. This was fault causing avoidable distress. The Council will apologise for its poor complaint responses. There was no fault in placing Mrs Y in a care home in a different …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
22-001-875 — T L C Care & Support
Summary: We will not investigate this complaint about noise from a residential care home. This is because there is not enough evidence of fault by the Care Provider. If Mrs X thinks the noise from the care home is a statutory nuisance she can complain to the Council.
LGO (Local Government & …
Adult Care Services
May 2022
22-001-572 — East Riding of Yorkshire Council
Summary: We will not investigate Mrs X’s complaint about matters relating to her mother’s care home placement between late 2017 and early 2020. The complaint lies outside our jurisdiction because it is late and I see no good grounds to consider it now.
LGO (Local Government & …
Adult Care Services
Jun 2022
21-007-565 — Aegis Residential Care Homes Limited
Summary: The care provider did not provide sufficiently clear information about the fees or placement before Mr and Mrs X moved into the home. It should repay the deposit amount to Ms A.
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-015-115 — City of Wolverhampton Council
Summary: Mrs B complained about the care provided to her mother Mrs C during a two week stay at a care home commissioned by the Council. We have not found fault with the Council.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2022
22-002-749 — Luton Borough Council
Summary: We will not investigate Mrs D’s complaint about the care Mrs E received from her former care provider. This is because further investigation by the Ombudsman could not add to the care provider’s response or make a finding of the kind Mrs D wants.
LGO (Local Government & …
Adult Care Services
Jun 2022
22-004-036 — Hill Care 3 Limited
Summary: We will not investigate Mrs X’s complaint the Care Home used a hoist to transfer her father, Mr Y whilst he was having respite. That is because there is insufficient of fault in the Care Home’s actions to justify our involvement. The Care Provider has already apologised to Mrs …
LGO (Local Government & …
Adult Care Services
Jul 2022
21-017-902 — Burlington Care (Yorkshire) Limited
Summary: The Care Provider failed to identify some upheld points of complaint as poor care. It also failed to properly acknowledge Ms X’s distress.
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-016-775 — Christchurch Fairmile Village LLP
Summary: We will not investigate this complaint about adult social care provision, because the injustice claimed is not serious enough to warrant our involvement and we could not add to the Care Provider’s investigation.
LGO (Local Government & …
Adult Care Services
Jul 2022
21-006-282 — Georgians (Boston) Limited(The)
Summary: Mrs X complained about several aspects of poor care she received while resident at The Georgians Nursing Home. We have identified some areas of fault including poor record keeping, uncertainty about care provision and complaint handling. To remedy the injustice caused, the Care Home has agreed to apologise, make …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-013-311 — Ideal Carehomes (Number One) Limited
Summary: Mrs X complained the care home failed to provide adequate care for an illness her mother Mrs Y was suffering from, during her respite stay. Mrs X said Mrs Y suffered unnecessarily during her stay and subsequently died. We do not find fault with the care providers actions.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2022
21-012-375 — West Sussex County Council
Summary: Mrs X complained, on behalf of her mother Mrs Y, about the poor standard of care provided to Mrs Y by a Care Home. We found the Council at fault. We recommended it apologise to Mrs X and Mrs Y, pay Mrs X £500 for distress, pay Mrs Y …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-018-453 — Care Line Homecare Limited
Summary: Mrs X complains about an allegation made against her son, the Care Provider’s failure to deal properly with her concerns and its decision to end its support. The Care Provider accepts it did not deal with her concerns properly and that if it had it should have been able …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-010-423 — Lancashire County Council
Summary: Mrs X complained that the Care Provider, acting on behalf of the Council, delayed advising family of the late Mrs Y’s fall. Also, that it unreasonably refused to allow her to return from hospital and did not deal with her complaint properly. Mrs X says Mrs Y was deeply …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-012-559 — London Borough of Hounslow
Summary: Ms X complained the Council failed to act in her husband, Mr Y’s, best interest when it obtained a deprivation of liberty authorisation to keep him at the Care Home which had previously found to have been providing him with poor care. There was no fault in how the …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
22-001-426 — Wood Green Nursing Home Ltd
Summary: We will not investigate this complaint about the residential care provided to the complainant’s aunt, the way the care provider responded to her and her uncle, and any unresolved dispute over standards and charges. This is because in different parts of the complaint there is either not enough evidence …
LGO (Local Government & …
Adult Care Services
Aug 2022
21-016-412 — Care UK Community Partnerships Limited
Summary: Mrs C complains the Care Provider was not transparent over care fees and failed to provide suitable care to Mr C which resulted in a decline in his health. The Care Provider is at fault for failing to keep full contemporaneous records about the support it provided Mr C …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-018-580 — Care UK Community Partnerships Limited
Summary: Mrs X complained about the care her father received and the accuracy of notes that were taken while he was resident in a care home. Mrs X said the poor care meant her father’s health deteriorated rapidly. We find the Care Provider at fault for failing to take and …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
21-017-241 — Monarch Healthcare Limited
Summary: Mrs X complained that Monarch Healthcare Limited failed to keep her mother, Mrs Y safe during her stay at Clifton Manor Residential Home in November 2021. The care home was not at fault for Mrs Y’s fall. However, the failure to return the unused milkshakes amounts to fault. This …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
21-017-570 — The Orders Of St. John Care Trust
Summary: We will not investigate this complaint about the Care Provider failing to manage Mr Y’s pain properly at the end of his life. We could not add to the investigation that has already taken place, and we could not provide a meaningful outcome for Ms X.
LGO (Local Government & …
Adult Care Services
Sep 2022
21-017-428 — Barchester Healthcare Homes Limited
Summary: Mrs C complains about the standard of care provided by the Care Provider. The Care Provider is at fault for failing to retain and record interventions which has caused uncertainty about whether it cared for Mrs C’s mother, Mrs D, properly. The Care Provider has accepted some fault, apologised, …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
22-001-337 — Bowbrook House
Summary: Mrs X has complained about the care her husband, Mr X, received from a care provider, causing him to deteriorate rapidly. Mrs X also complained the Care Provider was critical of the care she had provided him. We find the Care Provider at fault for failing to take and …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-017-118 — Brunelcare
Summary: Ms C complained about the care her (late) father received at his care home. We found there was fault with regards to some of the aspects of the support Mr F received at the care home. The care home has agreed to apologise for the distress this caused and …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
22-000-102 — Warwickshire County Council
Summary: The Council acknowledges Mrs X received poor care and treatment by the commissioned care provider. Mrs X suffered severe dehydration, often expressed pain which was not acted on and was not treated with dignity. The Council will now offer a sum in recognition of the harm caused to Mrs …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
22-001-843 — Saint Jude Residential Care Home Limited
Summary: there was no fault in the care provided by Saint Jude Residential Care Home Limited to the complainant’s mother or in its consideration of, or planning for, her care needs. However, its handling of Ms B’s complaint did not comply with its own policy on this and amounts to …
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
22-000-034 — Pine View Care Homes Ltd
Summary: There was fault in the way the Home communicated with the family of a resident and its failure to respond to the family’s complaints. There was also fault in the Home’s record keeping. This has caused the family distress and we recommend that the Home apologises to the family …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
23-018-301 — Barchester Healthcare Homes Limited
Summary: We will not investigate Mr X’s complaint about the standard of care provided to his mother-in-law by her care home. This is because an investigation would not lead to any different findings or outcomes.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
23-017-162 — Your Health Ltd
Summary: We will not investigate this late complaint from Mr X about Mr Y’s transfer to an unsuitable room within his residential care home. There is not a good reason for the delay in bringing the matter to the Ombudsman. We also could not achieve the outcome Mr X seeks.
LGO (Local Government & …
Adult Care Services
Apr 2024
23-009-243 — Rotherwood Healthcare (St Georges Park) Limited
Summary: The care provider charged the fees for the notice period in accordance with the contract which Mrs X signed. The care provider acknowledges there were some inadequacies in the decoration of Mr X’s room and the operation of the call buzzer, and there are some discrepancies in the response …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
23-021-168 — Park Homes (UK) Limited
Summary: We cannot investigate this complaint about adult social care provided in Scotland.
LGO (Local Government & …
Adult Care Services
Apr 2024