Complaint record keeping failures
Failures in maintaining accurate and procedural records for managing complaints in residential care homes.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
95match
43 - Church in Wales record-keeping policies
The Church in Wales should introduce record-keeping policies relating to safeguarding, complaints and whistleblowing. These should be implemented consistently across dioceses. The Church should develop policies and training on the information that must be recorded in files. The Church should provide its provincial safeguarding officers with the right to see personnel files of clergy, office holders, employees or...
Matched on
terms: complaint, keeping, record
Inquiry recommendation
90match
L20 - Compliance Record Keeping
The Board should have both the power and a duty to ensure that all breaches of the standards code that it considers are recorded as such and that proper data is kept that records the extent to which complaints have been made and their outcome; this information should be made available to the public in a way that...
Matched on
terms: complaint, keeping, record
Inquiry recommendation
87match
R40 - Record all complaints in electronic system
In HSCTs all complaints, regardless of whether they are resolved immediately at ward level, should be recorded in the Trust’s electronic complaints management system. In private and third sector facilities the Registered Home Manager should be informed of all concerns raised and must record such concerns and any action taken.
Matched on
terms: complaint, record
Inquiry recommendation
82match
AFA-1 - Patient focus and complaints
The Inquiry recommends that the Trust and Department work together to ensure there is: • A specific programme of work to strengthen patient involvement, improve communication, and ensure patients and families are treated as partners in care. • Direct communication with patients as standard practice. • More effective handling of concerns and complaints, with an emphasis on early...
Matched on
terms: complaint, record
PFD report
81match
John Duckenfield
The coroner noted false assertions by staff regarding patient observations and GP calls, a failure to record vital observations, and that the care home's records were inaccurate and misleading.
Matched on
terms: failure, record
PFD report
81match
Margaret Greenacre
The coroner noted delays in statutory notifications of incidents to the CQC, including one that was never reported, potentially hindering investigations. Concerns were also raised regarding poor record-keeping at the care home, where care notes did not accurately reflect residents' needs and care plans were not updated.
Matched on
terms: keeping, record
LGO / SPSO decision
80match
21-011-711d - CSH Surrey (21 011 711d)
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track NHS continuing healthcare. Those faults caused Mrs P’s...
Matched on
terms: complaint, keeping, record
LGO / SPSO decision
80match
21-011-711c - Woking and Sam Beare Hospice and Wellbeing Care (21 011 711c)
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track NHS continuing healthcare. Those faults caused Mrs P’s...
Matched on
terms: complaint, keeping, record
Inquiry recommendation
78match
RHI-28 - Record Keeping Culture and Audit
The culture and practice of record keeping and access to records within the Northern Ireland Civil Service needs to change so that staff responsible for a given area of work have easy access to the analysis and decisions underpinning the policy or initiative on which they are engaged. Regular audits of record keeping should be undertaken so as...
Matched on
terms: keeping, record
PFD report
77match
William Tolen
The coroner identified inadequate and fragmented record-keeping at the care home, impacting staff's ability to track care and confirm facts. Concerns included insufficient staff training for medical situations, delays in podiatry care, and the absence of a post-incident review.
Matched on
terms: keeping, record
LGO / SPSO decision
76match
21-014-433 - London Borough of Lewisham
Summary: The Council failed to provide evidence of compliance with a remedy it previously agreed with the Ombudsman. In the original complaint, we found the Council failed to investigate Mr B’s complaint The Council agreed to make a financial payment to recognise the impact of its fault. The Council was at fault for not paying Mr B or...
Matched on
terms: complaint, keeping, record
LGO / SPSO decision
76match
21-004-840 - London Borough of Waltham Forest
Summary: Mr X complained he was excluded from the Council’s Rapid Employment Service. He also complained the Council’s investigation of his complaint was flawed. The Ombudsman found no evidence the Council excluded Mr X from its service. The Ombudsman did find fault in the Council’s record keeping and in the complaint process. It agreed to apologise to Mr...
Matched on
terms: complaint, keeping, record
LGO / SPSO decision
76match
21-000-037 - Sheffield City Council
Summary: The Ombudsman found fault by the Council on Ms J’s complaint about its failure to take enforcement action against noisy neighbours. It failed to provide us with complete records, show it considered and reached a decision on her acoustic report, and failed to show whether officers properly considered and reviewed the case after witnessing two breaches of...
Matched on
terms: complaint, failure, record
LGO / SPSO decision
76match
21-018-132 - Surrey County Council
Summary: Mrs X complains the Council has not completed some of the agreed remedy actions after it upheld her complaints following an investigation under the children’s statutory complaints procedure. The Council is at fault. It has not completed some of the actions agreed. There was also poor record keeping which has caused uncertainty about how the decision to...
Matched on
terms: complaint, keeping, record
Committee recommendation
74match
#21 - Analyse complaint data to identify systemic issues and report quarterly on service improvements.
Users of such a service must receive assurance that information about complaints and failures is being aggregated and used proactively to improve systems and services, not just to effect redress to the individual. In order to achieve this, the Department should: • analyse information gathered through this mechanism both to hold operators to account for resolving specific problems...
Matched on
terms: complaint, failure
Committee recommendation
74match
#15 - Clarify commission complaint procedures for maladministration and Police Ombudsman's investigative powers over state actors.
The Joint Framework and Troubles Bill partially fill the gap in commission accountability left by the Legacy Act. It is still unclear, however, what procedure there is to complain about maladministration or service failure by the commission. The Government must also clarify whether the powers of the Police Ombudsman for Northern Ireland to investigate a relevant offence apply...
Matched on
terms: complaint, failure
PFD report
73match
Joyce Hartford
The coroner noted incomplete and inaccurate nursing tools, assessments, records, and discharge summaries. Despite audits by the Trust to improve record keeping, no material improvement in standards was observed.
Matched on
terms: keeping, record
PFD report
73match
Sidney Baker
The coroner noted a lack of contemporaneous documentation for referrals and inaccuracies in the patient's care plan, including vital weight monitoring information. Concerns were also raised about the generally poor quality of record-keeping.
Matched on
terms: keeping, record
Inquiry recommendation
73match
BRIS-36 - Establish independent, swift, and thorough complaints handling with advocacy for patients
Complaints should be dealt with swiftly and thoroughly, keeping the patient (and carer) informed. There should be a strong independent element, not part of the trust’s management or board, in any body considering serious complaints which require formal investigation. An independent advocacy service should be established to assist patients (and carers).
Matched on
terms: complaint, keeping
Inquiry recommendation
73match
31 - Fundamental review of NHS complaints system
The NHS complaints system in the University Hospitals of Morecambe Bay NHS Foundation Trust failed relatives at almost every turn. Although it was not within our remit to examine the operation of the NHS complaints system nationally, both the nature of the failures and persistent comment from elsewhere lead us to suppose that this is not unique to...
Matched on
terms: complaint, failure
CQC action
73match
Park Grange Care Home
There was not an effective system in place to ensure concerns and complaints were recorded and responded to appropriately.
Matched on
terms: complaint, record
CQC action
73match
B&H Care Ltd
The provider must ensure people's complaints and concerns are managed effectively to promote their health, safety and wellbeing, including having a system for independent investigation of complaints and maintaining records of complaints.
Matched on
terms: complaint, record
LGO / SPSO decision
72match
201103592 - Grampian NHS Board
Ms C was injured when there was an accident involving the stair lift on which she was being transported by a member of the Scottish Ambulance Service (the Service) to a hospital appointment. She complained that, following the accident, she reported the matter to the receptionist at the clinic and was told that someone (apparently the lead nurse...
Matched on
terms: complaint, failure
ICIBI recommendation
72match
An inspection of the Home Office’s use of sanctions and penalties
2. (Without waiting to complete any more comprehensive reviews), ensure that the quality and extent of record-keeping and data collection are sufficient to provide clear insights into the efficiency and effectiveness of the processes supporting each sanction and penalty currently in use and, where this is not the case, take whatever actions are necessary to fix this in...
Matched on
terms: complaint, keeping, record
PFD report
69match
Kimberley Lindfield
The coroner raises concerns about the lack of an auditing process for the new mental health referral system, as well as the absence of clear written policies for increased patient observations and for clinical reviews responding to new risks. The report also notes the importance of reminding staff about record-keeping responsibilities and conducting periodic audits.
Matched on
terms: keeping, record
PFD report
69match
Marian Dale
Concerns were raised regarding the District Nursing Team's record-keeping system, where patient notes were held solely at the patient's address with no central contemporaneous record, leading to difficulties in evidence provision and post-death retrieval.
Matched on
terms: keeping, record
PFD report
69match
Peter Ross
Concerns were raised about a misreported CT C-spine scan, a reviewing surgeon's failure to note or escalate an abnormality, and the neurosurgical team not reviewing images before surgery. This was compounded by repeated communication failures between clinical teams and poorly maintained clinical records.
Matched on
terms: failure, record
Inquiry recommendation
69match
WATE-(4) - Define specific duties for Children's Complaints Officers, prioritising child's best interests
Amongst the duties of the Children's Complaints Officer should be: (a) to act in the best interests of the child; (b) on receiving a complaint, to see the affected child and the complainant, if it is not the affected child; (c) thereafter to notify and consult with appropriate line managers about the further handling of the complaint, including:...
Matched on
terms: complaint, record
IOPC learning recommendation
69match
Complaints made against a senior Lancashire police officer by two retired senior police officers - Lancashire Police, June...
The IOPC recommends that Lancashire Police should ensure all policy decisions and rationales should be documented appropriately during the course of its investigations to record strategic decisions, operational priorities, and strategic, critical and investigative issues. This follows an independent IOPC investigation into a Misconduct Investigation carried out by Lancashire Police in 2015. Our investigation found that no-one involved...
Matched on
terms: complaint, record
CQC action
69match
Kingfishers Nursing Home
The registered person failed to establish and operate effectively an accessible system for identifying, receiving, recording, handling and responding to complaints by service users and others in relation to the carrying on of the regulated activity.
Matched on
terms: complaint, record
CQC action
69match
Heritage Healthcare-Middlesbrough
The provider must ensure complaints are investigated appropriately and dealt with effectively, with proper records maintained.
Matched on
terms: complaint, record
CQC action
69match
Kingsley Nursing Home
The registered manager and provider failed to: 2. have an effective system to receive, record, investigate or respond to complaints. 16 (2)
Matched on
terms: complaint, record
CQC action
69match
Barton Park Nursing Home
Complaints were not being recorded or responded to in line with the registered providers complaints policy.
Matched on
terms: complaint, record
Inquiry recommendation
66match
F121 - Learning and information from complaints
The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should be charged with informing themselves of such complaints and the detail underlying them.
Matched on
terms: complaint
Inquiry recommendation
66match
F118 - Learning and information from complaints
Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In any case where the complainant or, if different, the patient, refuses to agree, or for some other reason publication of an upheld, clinically related complaint is not possible,...
Matched on
terms: complaint
Committee recommendation
66match
#26 - AIRE service lacks follow-up mechanisms, creating accountability gap for complaints
Migrant Help is not contracted to follow up on or monitor issues and does not have sight of the response from providers and the Home Office. This creates a significant gap in accountability. We recognise the value of enabling asylum seekers to raise concerns separately from accommodation providers and the Home Office itself. However, to ensure that concerns...
Matched on
terms: complaint
PFD report
65match
Clive Clinton
The coroner noted apparent failings in the care home's complaints procedure, which allowed staff to withhold concerns from senior management. There was also a lack of information for families on how to direct complaints to a more senior level within the organisation.
Matched on
terms: complaint
Committee recommendation
65match
#27 - First Report - The Regulation of Social Housing
The introduction of the Housing Ombudsman’s complaint handling code and complaint handling failure orders must drive improvement and consistency in the way providers respond to complaints. We are pleased therefore that the Government is legislating through the Social Housing (Regulation) Bill to place the power to establish such a code on a statutory footing. It is not clear,...
Matched on
terms: complaint, failure
CQC action
65match
Doncaster Royal Infirmary
The trust should ensure it continues to operate effective systems to respond to complaints and take appropriate action without delay to any failures identified by a complaint or the investigation of a complaint.
Matched on
terms: complaint, failure
CQC action
65match
Castle Hill Hospital
The service must ensure that an effective and timely system for identifying, receiving, recording, handling and responding to complaints is clear to those raising concerns or making a complaint.
Matched on
terms: complaint, record
CQC action
65match
Sunderland Eye Infirmary
Review the practice of recording complaints in patients’ notes in line with best practice guidance.
Matched on
terms: complaint, record
CQC action
65match
Winterton House
The registered person did not operate an effective system for identifying, receiving, recording, handling or responding to complaints.
Matched on
terms: complaint, record
CQC action
65match
Ashmore House
The provider must establish and operate an accessible system for identifying, receiving, recording, handling and responding to complaints.
Matched on
terms: complaint, record
IOPC learning recommendation
65match
Investigation into response to a concern for welfare - Greater Manchester Police, April 2021
The IOPC recommends that Greater Manchester Police takes steps to improve their record keeping and archiving around when changes are made to the Call Handling Minimum Standards. This could be achieved by way of implementing a version control system on any changes to the standards, making sure to document the date of the change, who made the change,...
Matched on
terms: keeping, record
Inquiry recommendation
65match
14 - Recording cell-share requests
The guidelines should contain guidance on how such requests should be recorded, but there is no need for such requests to be treated as formal applications under the requests and complaints procedures.
Matched on
terms: complaint, record
Committee recommendation
64match
#9 - Seventeenth Report - Government’s contracts with Randox Laboratories Ltd
In addition to the wider efforts to improve basic documentation, the Department told us that it had introduced measures such as spot checks by the principal private secretary to reinforce the importance of proper record-keeping in private offices. The Department explained that the measures were designed to ensure staff in private offices and policy teams always kept records...
Matched on
terms: keeping, record
GIRFT recommendation
64match
Respiratory Medicine
Reduce litigation costs by application of the GIRFT five-point plan. Share learning by ensuring claims, inquests and complaints are reviewed in regular M&M meetings. a) Assess benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts would have received this information in the GIRFT 'Litigation data pack'. b) Discuss with the legal...
Matched on
terms: complaint, record
IMB recommendation
64match
Downview (2023)
We reported previously that it was difficult to monitor the levels of complaints within healthcare as the system of recording appeared not to function adequately.
Matched on
terms: complaint, record
LGO / SPSO decision
64match
21-004-999 - Bristol City Council
Summary: The Ombudsman found fault by the Council on Mrs Q’s complaint of it failing to act against a neighbouring allotment tenant after upholding her complaint and failing to respond to her correspondence. It failed to keep proper records, could not show it did what it said it would do, delayed responding to her formal complaint, and delayed...
Matched on
terms: complaint, record
LGO / SPSO decision
64match
22-002-492 - London Borough of Haringey
Summary: We will not investigate this complaint about the Council’s complaints team failing to respond to the complainant’s request for information. This is because the Council’s complaints team has now apologised for its failure to respond but confirmed another team did respond to the complainant’s concerns. So, there is nothing further to be gained by investigating.
Matched on
terms: complaint, failure