Ineffective Staff Deployment
Failure to effectively deploy staff to meet service users' needs, coupled with unclear or inadequate training and induction records.
Source spread
Where this theme appears
This theme appears across 23 independent accountability sources, so the source mix matters as much as the headline total.
40 inquiry recs
21 PFD reports
85 committee recs
39 HSSIB recs
193 CQC actions
9 HMICFRS recs
6 ICIBI recs
9 PPO recs
6 IOPC recs
11 NAO recs
42 IMB recs
1 Scottish FAI
4 Article 2 learning points
14 detention investigation recs
52 DHR recs
13 LGO/SPSO decisions
1 CJINI report
12 CQC enforcement actions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(40)
18 — Role of general practitioners
Recommendation: The employment of general practitioners should be rationalised to cover the day-to-day needs of long-stay patients: but their valuable contribution should not be regarded as a substitute for specialist services.
Unknown
37 — Protect clinicians' time for patient care
Recommendation: No clinician shall be asked to take on responsibilities that impair the ability to carry out patient care to the appropriate standard.
Unknown
121 — Limit interviews per interviewer per day
Recommendation: No more than two investigative interviews per interviewer per day should be undertaken and their workloads should be regularly monitored (17.61).
Unknown
MAI-93 — 24-hour qualified command structure rostering
Recommendation: The College of Policing and His Majesty's Inspectorate of Constabulary and Fire and Rescue Services should ensure that each police service has in place a system that means appropriately qualified and experienced personnel are rostered 24 hours each day so …
Gov response: Accepted in full
Accepted
MAI-82 — Allocate best-trained operators to Major Incident roles
Recommendation: North West Fire Control should review how it allocates the best-trained and most suitable Control Room Operators to roles during a Major Incident. It should consider whether it is beneficial to allocate a Control Room Operator to monitor communications on …
Gov response: Accepted in full
Accepted
MAI-76 — Review HART mobilisation policies
Recommendation: North West Ambulance Service should review its policies for mobilising the Hazardous Area Response Team resource, to ensure that this team is available as soon as possible for an emergency where its specialist skills are required.
Gov response: Accepted in full
Accepted
MAI-72 — Review NWAS Tactical Advisor rostering coverage
Recommendation: North West Ambulance Service should review how it rosters Tactical Advisors and National Interagency Liaison Officers so as to ensure that there is adequate geographical coverage enabling those on duty to arrive promptly at the scene of any Major Incident.
Gov response: Accepted in full
Accepted
MAI-6 — Ensure Airwave Tactical Advisors availability
Recommendation: All police services should ensure that they have made adequate provision for Airwave Tactical Advisors, in particular that an identified Airwave Tactical Advisor is either on duty or on call at all times.
Gov response: Accepted in full
Accepted
41 — Control Room manning and qualification
Recommendation: The Control Room should at all times be in the charge of a person trained and qualified to undertake the work of Control Room operator. The Control Room should be manned at all times (para 18.35).
Unknown
75 — Mental health awareness training evaluation
Recommendation: The responses of those members of staff who have attended the mental health awareness training course should be analysed to determine whether the course can be improved. The number of front line staff attending the course should be increased, resources …
Unknown
66 — Assigning personal officers to prisoners
Recommendation: Personal officers should be assigned to individual prisoners, not to a group of cells. They should be members of a small team, so that when a prisoner’s personal officer is not on duty, the prisoner can approach another member of …
Unknown
65 — Mandatory personal officer schemes
Recommendation: It should be mandatory for all establishments to have a personal officer scheme. That includes busy local prisons, although if time for personal officer work is limited, it should be used constructively.
Unknown
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
25 — GWT to monitor maintenance staff workload
Recommendation: GWT should regularly monitor the workload of all maintenance staff (para 15.6).
Unknown
34 — Control overtime
Recommendation: Overtime worked by building and other staff should be more strictly controlled.
Unknown
24 — Separate domestic and nursing duties
Recommendation: Domestic duties should, so far as possible, be separated from nursing duties and a special programme started for recruiting and training domestic workers.
Unknown
10 — At least four new consultant psychiatrists
Recommendation: At least four new consultant psychiatrists should be appointed to Whittingham Hospital, with appropriate junior staff, and in making appointments the special needs of long-stay psychiatric and geriatric patients should be borne in mind. There will need to be an …
Unknown
77 — Measures for mentally disordered prisoners on wings
Recommendation: The measures which should be taken to minimise the risk which a mentally disordered prisoner on ordinary location poses to staff and other inmates includes: • not placing such a prisoner in a shared cell • if such a prisoner …
Unknown
R9 — Integrated workforce plans
Recommendation: Each facility or service should have an integrated workforce plan that includes all allied health professionals (AHPs) and all staff involved in patient care. This should be based upon the assessed needs of the service user and must include protected …
No response yet
R13 — Clear nursing responsibility line
Recommendation: Health Boards should ensure that there is a clear and effective line of professional responsibility between the ward and the Board.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
ETI-3 — Staffing Guidance
Recommendation: The guidance mentioned in the first recommendation should include: advice concerning the circumstances in which civil servants in the inquiry team may properly transfer to posts, other than promoted posts, within other government departments or agencies; which positions within the …
Gov response: We are working through all of these recommendations, but I can report that additional guidance similar to that suggested is already in development with reference to the efficient establishment and delivery of public inquiries and …
Response Unclear
9 — Improve joint working between hospital sites
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify an approach to developing better joint working between its main hospital sites, including the development and operation of common policies, systems and standards. Whilst we do not believe that …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
5 — Promote effective multidisciplinary team-working
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and develop measures that will promote effective multidisciplinary team-working, in particular between paediatricians, obstetricians, midwives and neonatal staff. These measures should include, but not be limited to, joint training …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
MAI-10 — Resolve paramedic-driver shortage in mass casualties
Recommendation: A significant issue in a mass casualty situation is that all of those paramedics who have arrived in ambulances may be required for the treatment of casualties, so that no paramedic is available to drive patients to hospital. The Department …
Gov response: Accepted in full
Accepted
FENN-96 — Allocate physically suitable staff to roles, ensuring station safety balance
Recommendation: London Underground shall only allocate staff to a role for which they are physically suitable. In the cause of safety, a proper balance must be ensured at each station.
Unknown
FENN-92 — Appoint only qualified relief supervisory staff to stations
Recommendation: Relief supervisory staff shall only be appointed to a station for which they are qualified.
Unknown
FENN-91 — Appoint and train station 'landlords' with total management responsibility
Recommendation: A station 'landlord' shall be appointed and trained to have total management responsibility at each major station or group of smaller stations.
Unknown
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
FLIX-210 (i) — Exercise special care when making decisions during important post vacancies
Recommendation: That when an important post is vacant special care should be exercised when decisions have to be taken which would normally be taken by or on the advice of the holder of the vacant post. This, in the present instance, …
Unknown
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
R17 — Ward admission responsibility
Recommendation: Health Boards should ensure that where there is risk of cross infection, the nurse in charge of a ward has ultimate responsibility for admission of patients to the ward or bay. Any such decision should be based on a full …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R8 — Reorganisation management structure
Recommendation: In any major structural reorganisation in the NHS in Scotland the Board or Boards responsible should ensure that an effective and stable management structure is in place for the success of the project and the maintenance of patient safety throughout …
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
ETI-19 — Collaborative Delivery
Recommendation: At all stages of the project there should be a collaborative approach to delivering it. This should include the co-location of representatives from each organisation relevant to the particular stage reached and having an interest in its completion to enable …
Gov response: The Inquiry Report describes some of the damaging behaviours adopted during project delivery by various parties. The advantage of co locating representatives having an interest in project completion is understood and indeed was successfully adopted …
Accepted
ETI-18 — Interviews of Key Personnel in Readiness Reviews
Recommendation: As part of their investigations, representatives of OGC undertaking an independent “readiness review” of a publicly funded project and representatives of any person, including representatives of any public body such as Audit Scotland, undertaking a review of the progress of …
Gov response: While this Recommendation is for third parties who may undertake a readiness review or audit of a publicly funded project in future, it is recommended that the Council agrees to support any such review or …
Noted
RHI-24 — Staff Move Sequencing
Recommendation: Senior managers in the Civil Service must take responsibility for guiding and, where necessary, sequencing the timing of staff moves so that continuity of business is secured. This includes allowing sufficient time for transferring staff to hand over, and discuss …
Gov response: These recommendations can be accepted in full. They have been addressed through work to date, including: • job-specific appointments within the NICS generalist grades; • the piloting of Cabinet Office’s “Commercial Skills Assessment and Development …
Accepted
BAHA-41 — Detention Sergeant Role
Recommendation: On operations where CPERS may be taken there should be a Senior Non-Commisioned Officer (NCO) who acts as the “Detention Sergeant” who has responsibility for the administrative aspects of CPERS handling. In most cases, it would be appropriate for the …
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
BAHA-40 — Battlegroup Detention Officer
Recommendation: Each Battlegroup should have a “Detention Officer” being a commissioned officer within Battlegroup Headquarters. The role should encompass coordination and management of CPERS; acting as a focus on CPERS matters during mission specific training; ensuring that Military Annual Training Test …
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
JB-15.14 — Require trained CMP manager for covert monitoring posts
Recommendation: CMPs should not be established without the appointment of a properly trained CMP manager, whose responsibility it should be to appoint a team of CMOs, once satisfied from proper assessment as to their qualifications and ability.
Gov response: The previous MOG and MOS do have relevant sections in relation to this recommendation but, again, have been strengthened as shown here: Covert Audio Intrusive Surveillance & Covert Monitoring Posts Staffing (Extract) Where a CMP …
Noted
14 — Review clinical leadership arrangements
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review arrangements for clinical leadership in obstetrics, paediatrics and midwifery, to ensure that the right people are in place with appropriate skills and support. The Trust has implemented change at …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
7 — Audit maternity and paediatric services
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
Prevention of Future Deaths reports(21)
Keith Samuel Peters
Concerns: The coroner raised concerns about the allocation of Mr Peters' case to an officer on leave, insufficient prioritisation of the assessment, and the absence of a system to reallocate cases that could not be completed within the required 28-day period.
Response (Bolton Council): • The Council stated it had cascaded lessons learned from the case throughout the organisation. • The Council stated it had implemented developments and measures to improve systems, processes, and … (AI summary)
Responded
Henry Marsh
Concerns: The Home Treatment Team had an excessive number of patients, which created difficulties in holding effective multi-disciplinary meetings due to the large caseloads.
Response (Department of Health): • NHS England intends to map best practice guidance on Crisis Home Treatment Teams onto the mental health intelligence network. (AI summary)
Responded
Olive Nugent
Concerns: The coroner noted that the prioritisation of falls activator device responses was subjective, leading to delays for individuals unable to respond verbally, and that staffing levels were insufficient to meet demand.
Overdue
Blaise Farry
Concerns: The coroner noted insufficient staffing levels at HMP Wormwood Scrubs prevented the implementation of a nominated Officer scheme, despite previous recommendations from the Prisons Ombudsman.
Overdue
Ethan Johnson
Concerns: The coroner identified a lack of effective leadership and support for junior staff on the labour ward, particularly in escalating concerns about an abnormal CTG trace and ensuring a consultant's prompt attendance. This contributed to a lack of understanding regarding labour ward management.
Response (Milton Keynes University Hospitals NHS): • The Trust has implemented measures including strengthening preceptorship for newly qualified midwives, introducing intentional rounding, and establishing safety huddles. • Staff responsibilities for escalation and senior review have been … (AI summary)
Responded
Jasmine Lapsley
Concerns: The coroner identified a lack of reliable air support in North West Wales during night hours and an ineffective rota, communication, and recruitment process for Community First Responders. Concerns were also raised about the Welsh Ambulance Service Trust not increasing resources for seasonal population increases.
Response (Welsh Government): • The Welsh Air Ambulance is expanding its fleet, with an additional helicopter in July 2016 and funding secured for three more in early 2017. • A pilot of hand-held … (AI summary)
Responded
Jamie Fairclough
Concerns: The coroner noted concerns regarding high caseloads for care coordinators, with some managing 75-80 service-users, and these levels persisting despite the Trust's plans for reduction and its own internal investigation findings.
Overdue
Errol Mann
Concerns: The coroner noted persistent significant staffing shortages in the Intensive Care Unit, particularly for Clinical Fellows, which affected consultants' ability to fully dedicate time to clinical care and impacted patient care. Concerns were raised about ongoing gaps in the rota, especially during summer months.
Overdue
Kathryn Richmond
Concerns: The South West Ambulance Service Trust did not operate staggered shifts, which meant multiple ambulances were simultaneously unavailable during meal breaks, reducing service capacity.
Response (Department of Health): • The Association of Ambulance Chief Executives (AACE) will incorporate lessons learned and actions taken by South Western Ambulance Service (SWAST) into its national database of Regulation 28 reports. • … (AI summary)
Overdue
Sharon Grierson
Concerns: The coroner noted a lack of understanding of capnography readings during CPR, insufficient coordination and situational awareness, and limited experience among senior staff in managing crisis situations.
Response (North Cumbria University Hospitals NHS Trust): • The Trust has delivered training in difficult airway management in emergency situations using its simulation suite in February 2017 and February 2018. • A business case has been approved … (AI summary)
Response (Department of Health): • National bodies committed to raising awareness among anaesthetists and trainees regarding capnography interpretation through publications and national meetings. • NHS Improvement is developing national guidance to support the introduction … (AI summary)
Responded
Faye Allen
Concerns: The interpretation of national ambulance service guidance for event staffing allowed first aiders in non-medical areas to be counted, potentially leading to actual medical staff in designated areas being significantly below recommended levels.
Response: • The National Ambulance Resilience Unit (NARU) completed a national review of its guidance document and drafted amendments to add clarity. • NARU will consult with relevant stakeholders on the … (AI summary)
Overdue
James Francis
Concerns: Ineffective shift handovers meant staff were unaware of a patient's recent fall and the need for increased observations, a gap compounded by insufficient management checks. There were significant delays in seeking medical advice for a deteriorating patient, and vital information was not adequately provided to the GP or paramedics.
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence stated that its guideline on head injury (CG176) is undergoing a surveillance review. • The review is likely to conclude that … (AI summary)
Response (Shaw Healthcare): • Shaw Healthcare implemented a 'Shift Handover Form' and a detailed handover process to improve communication of critical patient information. • A revised 'Prevention and Management of Falls Policy' was … (AI summary)
Responded
Lesley Mawby
Concerns: The coroner noted residual staffing shortages in the dietetic team, resulting in delayed weekday assessments and an inability to provide weekend cover.
Response (Stockport NHS Foundation Trust): • The Trust implemented a new streamlined referral process and conducts twice-daily triage by a senior dietitian. • A business case for increased therapy staffing is under development, and the … (AI summary)
Response (Stockport Clinical Commissioning Group): • The Clinical Commissioning Group requested a commissioning-led review to ensure consistent service levels. (AI summary)
Responded
Henry Holcombe
Concerns: The coroner noted staff non-compliance with the Trust's therapeutic engagement and observation policy, specifically regarding night-time observations of patients believed to be sleeping. This issue has recurred over time despite previous incident reports.
Response (Sussex Partnership NHS Trust): • The Trust confirmed it had strengthened internal monitoring arrangements and enhanced staff training provision, including for agency and bank staff. • Policy compliance is now reviewed weekly by Ward … (AI summary)
Responded
Rebecca Pykett
Concerns: The coroner identified a lack of a system to ensure that patients under the care of the CMHT were allocated an active Care Co-Ordinator. The allocation often appeared to be a "box ticking" exercise, with assigned individuals not fulfilling the required tasks such as seeing the patient or completing a care plan.
Response (NHS England): • NHS England is working with NHSX to support improvements in digital systems, including Electronic Patient Records, in mental health services. • £30 million was invested in 2020/21 to support … (AI summary)
Response (North Staffordshire Combined Healthcare): • The Trust implemented procedures to ensure adherence to its revised Care Management Policy, which details the Care Co-ordinator role and required timeframes. • Processes and procedures were reviewed, and … (AI summary)
Responded
Jack Taylor
Concerns: Mill View Hospital's reliance on police to return absconding patients is noted, due to insufficient staff and underutilised Mental Health Act powers. There are also gaps in the joint absent without leave policy regarding risk assessment grading and communication with police.
Response (Sussex Partnership NHS Foundation Trust): • A joint working group with Sussex Police was established to improve responses to patients absent without leave. • Work commenced on co-developing a missing persons template and a joint … (AI summary)
Response (Sussex Police): • Sussex Police established a joint working group with Sussex Partnership Foundation Trust to improve responses to absent patients and commenced work on a joint Missing Persons Template and action … (AI summary)
Responded
Benjamin Stroud
Concerns: The coroner noted that Mr Stroud's case was not discussed at a Multi-Disciplinary Team (MDT) meeting. Concerns were raised about the Care Coordinator making clinical decisions, such as not referring to an MDT, without documenting the rationale.
Overdue
Charlotte Comer
Concerns: The coroner noted the Trust's inability to understand how inconsistent care coordinator provision resulted from staff instability and high workloads. Additionally, there was no robust system to prevent senior clinicians from unilaterally overriding Multi-Disciplinary Team decisions.
Response (Herefordshire and Worcestershire Health and Care NHS Trust): • The Trust has implemented a key worker approach, reduced caseloads, and reinforced leadership structures within its Neighbourhood Mental Health Teams. • New systems and processes, including twice-weekly 'huddles', are … (AI summary)
Responded
Roy Walklet
Concerns: The coroner noted delays in urgent gastroscopies for A&E patients with gastric bleeds pending hospital bed allocation. Additionally, an allocated consultant did not review a patient on their ward list as the patient remained physically in A&E.
Overdue
Patricia Walton
Concerns: Insufficient medical practitioner cover over a bank holiday period meant no doctor assessed the patient's routine care needs, potentially being as detrimental as a lack of emergency cover.
Response (NHS England): • NHS England engaged with University Hospitals of Leicester NHS Trust regarding the concerns raised in the report. • NHS England noted that University Hospitals of Leicester NHS Trust had … (AI summary)
Response (University Hospital of Leicester): • The hospital has increased medical staffing at the site where the incident occurred. • During bank holiday and weekend periods, a medical consultant is rostered 9am to 5pm onsite, … (AI summary)
Responded
Lindy Aston
Concerns: The coroner identified that Mrs Aston was not appropriately categorised as a high-risk patient requiring immediate surgery at Kettering General Hospital, leading to a significant delay in life-saving intervention. The decision-making process for not operating at the hospital was unclear.
Response (Kettering General Hospital NHS Foundation Trust): • A Standard Operating Policy (SOP) was implemented to ensure emergency theatre capacity and guide the prioritisation of emergency operations. • The 'Stop the Line' initiative was introduced and rolled … (AI summary)
Responded
Select committee recommendations(85)— showing 50 strongest matches
#131 —
Recommendation: In the first instance, we heard about the importance of âmanageable caseloadsâ. 245 Kim Thornden-Edwards told us that a youth offending officer may be supervising â10 to 12 casesâ at a time, whereas Justin Russell said that âthe typical caseload …
Response attribution not verified
#26 —
Recommendation: The FCA and PRA must review how their supervisory staff are deployed to ensure greater consistency in the staffing of supervisory teams and to address reports of frequent rotation amongst supervisors.
Response attribution not verified
#22 —
Recommendation: We asked the Departments why there is such substantial variation in the time taken to settle claims. DBT responded that it is waiting for people to submit full claims on the Horizon Compensation Schemes and it is keen to pay …
#27 —
Recommendation: To support better prioritisation, we reiterate the recommendation made in the Office of Statistics Regulation’s report on the State of the Statistical System 2026, that the National Statistician, once appointed, should publish a baseline view of capacity across the statistical …
#25 —
Recommendation: While all similar public sector organisations can make a case for increased funding to deliver more, we conclude that poor internal processes, particularly around prioritisation, were more of an issue for organisational failings than the total funding envelope. Resource constraints …
#7 —
Recommendation: The need for immediate consolidation and prioritisation is a legitimate response to the short-term problems the ONS faces. It is essential in rebuilding trust with its key stakeholders. Nonetheless, there is a risk that this approach leads to stagnation, with …
#1 —
Recommendation: We recognise the hard work of many FCO staff and diplomats who worked around the clock and did an excellent job helping UK citizens get home. However, some posts performed more effectively than others and there are areas where efforts …
Response attribution not verified
#22 — HMRC attributes decreased compliance productivity to onboarding new, less experienced staff.
Recommendation: As its compliance productivity had fallen, we asked HMRC whether it could reassure us that it was delivering value for money. It said when it brings in new compliance resource it expects to see a dip in productivity before recovering. …
Response attribution not verified
#21 — HMRC’s compliance productivity has fallen despite increased staffing investments.
Recommendation: HMRC’s main measure of the performance of its compliance work is through tracking compliance yield arising from its interventions.38 In December 2022, the NAO reported that HMRC’s compliance work offers good value for money.39 In the five years prior to …
Response attribution not verified
#3 — HMRC's compliance productivity has significantly declined despite increased investment.
Recommendation: HMRC’s compliance productivity has declined, despite its increased focus on prevention and investment in digital systems and higher–skilled staff. HMRC’s compliance work offers high returns and good value for money but its compliance returns have declined from over £1.4 million …
Response attribution not verified
#22 — Department reviewing resource allocation to align with Industrial Strategy priority sectors
Recommendation: We asked the Department about its overall priorities and whether it had aligned its resources accordingly. The Department explained that when the former DIT and BEIS merged, two sets of teams came together, which it structured around 10 economic sectors. …
Response attribution not verified
#21 — Departmental sector team staffing levels lack correlation with industry importance or spending
Recommendation: Following its formation in February 2023, the Department consolidated teams from the former BEIS and DIT into 25 sector-facing teams within its Business Group. These sector teams vary by size and grade distribution. The Department’s Business Group also has teams …
Response attribution not verified
#5 — Review internal structures and resourcing to align with Industrial Strategy objectives and emerging issues.
Recommendation: There is a risk that the Department is not set up internally to support the aims of the forthcoming Industrial Strategy and to respond to ongoing issues facing UK businesses. The composition of sector teams in the Department’s Business Group …
Response attribution not verified
#21 — Significant variation in work coach headcount observed across different jobcentres and districts.
Recommendation: We followed this up by asking whether within districts there are areas that are performing better. The Department confirmed that within districts there is variation in headcount numbers at jobcentre level.47 The Department emphasised that it manages performance and attrition …
Response attribution not verified
#11 — Redeployment of work coaches for health conditions reduces support for other Universal Credit claimants.
Recommendation: In March 2025, the government published a green paper, Pathways to Work, which set out proposals to reform health and disability benefits and employment support, with the aim of providing tailored employment, health and skills support for claimants with a …
Response attribution not verified
#23 — Expand Jobcentre employer offer with DBT to promote better employment practices and diversity.
Recommendation: Jobcentres offer a golden opportunity for the Government to influence employers and to create more ‘good jobs’. DWP should work with the Department for Business and Trade to expand Jobcentre’s offer to employers. The two Departments should work together to …
Response attribution not verified
#22 — Rebuild employer trust by setting Jobcentre engagement targets and recruiting specialist liaison officers.
Recommendation: DWP needs to rebuild trust with employers. This will require making better use of its network of Jobcentres and the employer advisers who work in them. To start, DWP should consider setting individual Jobcentres targets for engaging local employers. This …
Response attribution not verified
#12 — Manage work coach capacity better by modelling demand and developing prioritisation frameworks.
Recommendation: We recommend that DWP looks at how to better manage work coach capacity, including modelling how its planned Jobcentre reforms will change demand for work coach time and capacity. In response to this inquiry, it should set out: • a …
Response attribution not verified
#11 — DWP personalised work coach support plans lack clear strategy and evidence base.
Recommendation: We were encouraged to hear that DWP wants work coaches to have more time with claimants and to deliver more personalised support. Coaching that is tailored to the aspirations of the service user and that seeks to identify the unique …
Response attribution not verified
#10 — Undertake a detailed review of the work coach model, evaluating impact and empowering coaches.
Recommendation: Over the next year, DWP should undertake a detailed review of its work coach model. It should evaluate the difference work coach support makes to employment outcomes for different groups, identifying those who would most benefit from more support and …
Response attribution not verified
#9 — Work coaches are ineffectively deployed with insufficient time for personalised claimant support.
Recommendation: Work coaches are an incredible resource but they are currently being ineffectively deployed. Work coaches often do not have enough time with claimants to have an impact, with many appointments no more than 10 minutes long: not nearly enough to …
Response attribution not verified
#16 — Border Force inadequately enforces personal import rules, lacking POAO understanding and focused teams.
Recommendation: Border Force is not adequately fulfilling its responsibility to enforce personal import rules relating to animal products; it has too many competing priorities and officers lack understanding of product of animal origin (POAO) rules and seizures. Border Force and port …
Response attribution not verified
#6 — Set out plan for effective deployment of skilled professionals in inclusive mainstream education.
Recommendation: As part of delivering a fully inclusive mainstream, the Government must set out how it will deliver, over time, a system in which highly skilled professionals, including educational psychologists and speech and language therapists, are less tied up in undertaking …
Response attribution not verified
#15 — Officer maintenance grant incentivises inefficient deployment of police officers in staff roles.
Recommendation: A number of stakeholders identified that the officer maintenance grant has led to police forces increasingly using officers in staff roles (that do not require a warranted police officer) – an expensive and inefficient practice.34 In written evidence, Leapwise estimated …
Response attribution not verified
#15 — Caution against mandating widespread implementation of hub and spoke systems in pharmacies.
Recommendation: While hub and spoke arrangements may be beneficial to some pharmacies, we do not believe this is a ‘silver bullet’ in terms of efficiencies. We urge the Government not to assume that hub and spoke alone will deliver the extra …
Response attribution not verified
#8 —
Recommendation: The expansion of the Bank’s remit has led to a rise in the Bank’s headcount and to an expansion of its management structure, resulting in four Deputy Governors and a significant number of Executive Directors. This expansion, particularly in relation …
Response attribution not verified
#43 —
Recommendation: HMPPS should continue investing in its IT systems, such that Probation staff can dedicate more time to people on probation (see also section starting at paragraph 166 on âmaking the most out of partnershipsâ on the partners of the Probation …
Response attribution not verified
#39 —
Recommendation: The Probation Service is going through an identity crisis. The role of a probation officer has changed in recent yearsâthe increased focus on public protection distracts the attention of probation staff away from least-serious offenders. Moreover, the expectation that they …
Response attribution not verified
#63 —
Recommendation: The UK’s fragmented police forces and limited military resources may struggle to handle the increased civil defence burden in the event of hostile actions, such as sabotage of CNI. The Government should thus consider the merits of establishing a centralised …
Response attribution not verified
#22 —
Recommendation: We are concerned by evidence which indicated that there are inconsistencies in the quality of supervision. Firms should expect consistency in the staff that supervise them and supervisors who understand their business.
Response attribution not verified
#16 —
Recommendation: The FCA and PRA must work to reduce authorisation timelines. This should be accompanied by a renewed cultural focus on consistent improvement of operational efficiency across all levels of the organisation.
Response attribution not verified
#14 —
Recommendation: Concerningly, we received evidence that the FCA and PRA are slower to process authorisations than regulators in competing jurisdictions, particularly in key areas such as the authorisation of new products, senior managers, and branches. This has negatively affected the UK’s …
Response attribution not verified
#8 —
Recommendation: Given the high return on investment HMRC gets from its compliance work with large businesses, we asked it why it did not spend more on the large business directorate. HMRC told us that it was recruiting 5,500 full- time equivalent …
Response status not verified
#13 —
Recommendation: The processing delays and backlogs have had a negative impact on individuals and employers.21 The written evidence we received highlighted the hardship, both human and economic, caused by the delays in processing applications as a result of the backlogs. For …
Response status not verified
#12 —
Recommendation: The number of applications waiting for the Department to make a decision almost trebled, from 21,700 at 31 March 2022 to 62,100 at 31 March 2025.18 The Department told us that it currently had around 66,000 applications awaiting a decision.19 …
Response status not verified
#11 —
Recommendation: Once an application for support has been approved, customers can submit claims for reimbursement of costs incurred.15 There has been a backlog of requests for payment, with the number of outstanding requests more than quadrupling from 6,900 at 31 March …
Response status not verified
#4 —
Recommendation: Planning for how resources are allocated across the asylum system is fragmented and often reactive, repeatedly shifting backlogs rather than reducing them. There is a recurring pattern in which delays are not fully resolved but instead shift from one part …
Response attribution not verified
#13 —
Recommendation: We know that many FCO staff went above and beyond to deliver admirable service in extremely difficult circumstances. However, there were areas where efforts fell short. By not adapting quickly to changing circumstances the FCO appeared out of touch with …
Response attribution not verified
#6 — Protect the distinct role of careers advisors and develop their professional training pathway
Recommendation: As part of the new service, DWP should protect the distinct role and skills of careers advisors. It will also need to define the future relationship between careers advisers and work coaches, which will be critical to the success of …
Response attribution not verified
#5 — Integrating careers advice into Jobcentres risks undermining its distinct professional role
Recommendation: Integrating careers advice into Jobcentres is an exciting opportunity: the culture of careers advice, with its focus on the individual and long-term outcomes, offers a blueprint to improve the culture of Jobcentres. However, there are risks that DWP will have …
Response attribution not verified
#67 — Develop joint SEND workforce plan to address shortages and re-deploy professionals therapeutically
Recommendation: The DfE and DHSC should urgently develop a joint SEND workforce plan to address shortages and build capacity across education, health, and care services. This should include explicit measures to deliver a shift in the deployment of educational psychologists, speech …
Response attribution not verified
#18 — Inflexible police workforce model and poor wellbeing reduce productivity and increase costs.
Recommendation: Written evidence from Leapwise, Sir Stephen House and the City of London Police all highlighted how an inflexible workforce model can undermine police productivity.42 Leapwise highlighted how poor workforce wellbeing is reducing workforce capacity, identifying that the proportion of police …
Response attribution not verified
#35 — Mandate CCRC senior leadership to establish a regular office presence and hybrid model.
Recommendation: We recommend that the senior leadership should have a regular presence in the office, particularly in light of recent events and the high-profile criticism directed at the Commission. In our view, it is imperative that the organisation moves towards a …
Response attribution not verified
#34 — Senior leaders' regular physical presence crucial for conveying operational effectiveness.
Recommendation: The regular physical presence of senior leaders in the office conveys, to staff and stakeholders, that the leadership is present, operational and effective. (Conclusion, Paragraph 96)
Response attribution not verified
#32 — Evaluate fully remote working's impact on CCRC efficiency, casework quality, and staff wellbeing.
Recommendation: Fundamentally, we question whether fully remote working is right for the Commission and urge the interim chair to evaluate its impact on the Commission’s efficiency, the quality of casework and on staff wellbeing and morale. (Recommendation, Paragraph 94)
Response attribution not verified
#31 — CCRC's fully remote working model poses concerns for complex investigative casework and staff interaction.
Recommendation: We were shocked by the CCRC leadership’s decision—quite out of line with the rest of the public sector where hybrid working prevails—to turn the organisation fully remote. We struggle to understand how investigative case work, with its complexities and potential …
Response attribution not verified
#25 — Review commissioner terms of appointment to enable greater contribution to CCRC operations.
Recommendation: We recommend that the terms of appointment for commissioners should be reviewed to enable them to make a greater contribution to the day-to-day running of the CCRC. (Recommendation, Paragraph 80)
Response attribution not verified
#136 —
Recommendation: Local planning authorities should work with local partners and, where relevant, upper- tier authorities to share expertise and drive economies of scale. The approach taken by Warwickshire County Council should be considered a best practice example and delivered through two-tier …
Response attribution not verified
#132 —
Recommendation: We heard that where LPAs can share or pool resources and expertise it can result in greater efficiencies. Warwickshire County Council currently has 16 ecologists on staff. 176 The team operates service level agreements with the district and borough councils …
Response attribution not verified
#36 —
Recommendation: The Probation Service found itself understaffed when it unified in 2021. This results in unmanageable caseloads and the profession being unattractive. Despite impressive recruitment campaigns in recent years, vacancy rates remain high. New recruits are inexperienced.
Gov response: 125. The Probation Service is working to attract and retain a strong and diverse workforce: supporting every individual to continually build their skills, whilst ensuring they feel valued for their work. 126. We have injected …
Position Not Stated
HSSIB safety recommendations(39)
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
How do you work with providers of temporary staff to understand the skills and experience of temporary workers so they can be used most effectively?
Learning Prompt
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
How do you ensure that the skills and experience of temporary workers are taken into account when redeployments are being considered?
Learning Prompt
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
How do you ensure that you are clearly advertising the skills required of a temporary worker to fill a rota gap?
Learning Prompt
Temporary staff – involvement in patient safety investigations
HSSIB recommends that NHS England updates the agency worker framework agreement criteria to explicitly require framework agreements to adhere to the staff support principles of the NHS England Patient Safety Incident Response Framework. This will improve patient safety as there …
Safety Recommendation
Patient care in temporary care environments
Does your organisation consider the staffing ratios needed to manage temporary care environments, including numbers, skill mix, experience and competencies?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation ensure enough time is allocated to district nursing visits based on individual patient needs?
Learning Prompt
Wrong site surgery – wrong patient: invasive procedures in outpatient settings
It would be beneficial if scheduling, resources, and organisational performance targets were considered relative to the associated demand for care and interventions, as staff workload may influence the integrity and sustainability of safety checks in an outpatient setting.
Safety Observation
The use of an appropriate flush fluid with arterial lines
It may be beneficial to recognise that workload and fatigue will influence the reliability of safety controls dependent on staff time and attention.
Safety Observation
Patients at risk of self-harm: continuous observation
Are staff being regularly rotated so that they are not undertaking continuous observation for more than 2 hours in line with national guidance?
Learning Prompt
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
Providers of mental health inpatient care can improve patient safety by ensuring that where professional judgement is used to help make workforce decisions, this accounts for ward physical environments, changes in patient acuity, and the individual mental and physical health …
Safety Observation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
HSSIB recommends that NHS England works collaboratively with relevant national bodies and stakeholders including professional regulators, the Department of Health and Social Care, and relevant royal colleges to: 1) Identify and clarify the goals of acute mental health inpatient care …
Safety Recommendation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
HSSIB recommends that The Shelford Group reviews and updates the Mental Health Optimal Staffing Tool on a regular basis following collection of recent data from mental health inpatient settings. This is to ensure the tool remains valid for potential changes …
Safety Recommendation
Medication not given: discharge from an acute hospital to the community
How does your organisation support staff to take rest breaks and reduce the risk of staff fatigue?
Learning Prompt
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
Work demands and capacity to respond Changes were identified in work processes, staffing levels and physical layout of the space in which staff were working, resulting from the pandemic. Membrane sweeps (a midwife or doctor uses a single finger to …
Learning Prompt
Treating Covid-19 patients using continuous positive airway pressure (CPAP) outside of a critical care unit
As part of our final investigation report we have provided six safety questions to improve patient care and outcomes. Do you have an operational policy that includes the areas of the hospital where non-invasive respiratory support can be provided? Does …
Learning Prompt
Recognition of the acutely ill infant
It may be beneficial if there is system-wide assessment of the capacity of the medical and non-medical workforce to support safe and sustainable staffing in emergency departments caring for children in England. The intention of the following safety observation is …
Safety Observation
Temporary staff – involvement in patient safety investigations
Can you work with employment agencies to create agreed methods of including temporary staff in learning responses through your contractual arrangements?
Learning Prompt
Temporary staff – involvement in patient safety investigations
Agencies providing temporary staff to the NHS can improve patient safety by facilitating the involvement of temporary staff in investigation processes, including interviews. This is to enable the investigation of patient safety incidents in line with the Patient Safety Incident …
Safety Observation
Patients at risk of self-harm: continuous observation
Are staff having adequate breaks, with ready access to water and food?
Learning Prompt
The impact of staff fatigue on patient safety
Has your organisation considered the principles and activities described in the Chartered Institute of Ergonomics and Human Factors white paper ‘Fatigue risk management for health and social care’?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation’s risk register identify fatigue risks?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation measure and monitor data relating to fatigue risks?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation capture data on fatigue through existing reporting and learning mechanisms?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation consider how the design of work processes can help to reduce fatigue?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation consider fatigue risk from a systems perspective to account for both individual and organisation factors impacting on staff fatigue?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation offer training and support to staff on fatigue risks and how these can be managed?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation have a person responsible for leading on fatigue risks?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation consider fatigue risk when responding to patient safety events
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation’s senior leadership understand fatigue risks and its link to patient safety?
Learning Prompt
The impact of staff fatigue on patient safety
Has your organisation considered the principles and activities described in the Chartered Institute of Ergonomics and Human Factors white paper ‘Fatigue risk management for health and social care’?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation’s risk register identify fatigue risks?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation measure and monitor data relating to fatigue risks?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation capture data on fatigue through existing reporting and learning mechanisms?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation consider how the design of work processes can help to reduce fatigue?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation consider fatigue risk from a systems perspective to account for both individual and organisation factors impacting on staff fatigue?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation offer training and support to staff on fatigue risks and how these can be managed?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation have a person responsible for leading on fatigue risks?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation consider fatigue risk when responding to patient safety events
Safety Action
The impact of staff fatigue on patient safety
Does your organisation’s senior leadership understand fatigue risks and its link to patient safety?
Safety Action
NCEPOD recommendations(4)
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
CQC inspection actions(193)— showing 50 strongest matches
William Harvey Hospital
The trust should ensure staff working under their enhanced observation framework are given suitable rest periods in line with their policy. Regulation 18(2)(a): Staffing.
Should Do
The Princess Alexandra Hospital
The trust must ensure there are effective escalation procedures in place in the event of staff shortages.
Must Do
The Ipswich Hospital
The service must ensure the delivery suite coordinator is always supernumerary.
Must Do
Salford Royal Hospital
The service should continue to take action to enlist a clinical director of general and oral surgery and ensure that all required staff have job plans in place.
Should Do
Saint Mary's Hospital
The trust must ensure they deploy enough sufficiently skilled and experienced staff to appropriately assess and care for women and birthing people and mitigate risks in a timely manner. Regulation 18(1)
Must Do
Royal Victoria Infirmary
The service should consider a review of staffing on the Paediatric Intensive Care Unit to ensure that the skill mix supports the acuity of patients.
Should Do
Royal Hallamshire Hospital
The trust should ensure that consultants requested for administering an epidural are available within 30 minutes of being required.
Should Do
Rochdale Infirmary
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Must Do
Orpington Hospital
The trust should ensure there are enough staff on duty to enable the delivery of patient care needs in a responsive manner.
Should Do
North Middlesex University Hospital
The service must ensure vacant shifts are filled with appropriate staff so they can deliver the appropriate care for patients in line with their care plans and risk assessments and keep them safe.
Must Do
North Manchester General Hospital
The trust should ensure review of consultant weekend cover arrangements, implementation of twice daily ward rounds and block shifts to meet best practice guidance.
Should Do
North Manchester General Hospital
The trust must ensure they deploy enough sufficiently skilled and experienced staff to appropriately assess and care for women and birthing people and mitigate risks in a timely manner. Regulation 18(1)
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
North Devon District Hospital
The service must ensure labour ward coordinators maintain their supernumerary status in line with the maternity incentive scheme 2022 safety action 5.Regulation18(1)
Must Do
Liverpool Women's Hospital
The trust must ensure that there is sufficient shift leadership on matbase to keep women, babies and staff safe.
Must Do
Liverpool Walk in Centre
Review the systems and processes in place to ensure the right skill mix is in place across each of the Walk in Centres when staff are moved to cover for staff absence. This review should include the views of all …
Should Do
Kidderminster Hospital and Treatment Centre
Patients should receive physiotherapy during out of hours if required.
Should Do
Kettering General Hospital
The servicemust ensure a staffing tool that correctly calculates the number of patients in the emergency department, and adequately reflects acuity is used.
Must Do
John Radcliffe Hospital
The trust should ensure that the staffing skill mix and agency/bank usage meets the requirements as set out in The Faculty of Intensive Care Medicine ‘Guidelines for the Provision of Intensive Care Services’.
Should Do
Fleetwood Hospital
The trust should ensure the trust continues to review nursing and medical staffing within surgery so that the right people with the right skills are in the right locations.
Should Do
Doncaster Royal Infirmary
The trust must ensure the service’s medical and nursing staff match the planned numbers. They must also ensure the service has enough medical staff with appropriate skill mix on each shift.
Must Do
Clatterbridge Hospital
The services should act to minimise the number of times nursing staff are moved to cover escalation areas and areas outside of their speciality to help improve concerns of staff.
Should Do
Castle Hill Hospital
The service must ensure sufficient numbers of suitably qualified, competent, skilled and experienced medical staff are deployed to meet regulatory requirements, particularly in evenings and weekends.
Must Do
Castle Hill Hospital
The service must ensure sufficient numbers of suitably qualified, competent, skilled and experienced nursing staff are deployed to meet regulatory requirements.
Must Do
Arrowe Park Hospital
The service should ensure the staffing model and deployment used in triage does not delay access to assessment and treatment.
Should Do
Ambulance Headquarters, Bernicia House
Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
Must Do
Queen Charlottes and Chelsea Hospital
The trust should continue to ensure that there are sufficient staff to provide safe care.
Should Do
Homerton University Hospital
The service should ensure that it improves medical cover in triage and the emergency obstetric unit during the night and at weekends to reflect national recommendations.
Should Do
Homerton University Hospital
The service must ensure sufficient medical staffing is planned for triage to make sure women and birthing people are reviewed within safe time frames.
Must Do
Fairfield General Hospital
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Must Do
Fairfield General Hospital
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Must Do
Fairfield General Hospital
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Must Do
Fairfield General Hospital
The trust should ensure review of consultant weekend cover arrangements, implementation of twice daily ward rounds and block shifts to meet best practice guidance.
Should Do
Wexham Park Hospital
The service should consider the addition of a supernumerary co-ordinator to oversee staff and acuity across the whole maternity unit effectively.
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
The James Cook University Hospital
The service must review the escalation or surge process to ensure that on call rota is effective and there is not an over reliance on specialist midwives which impact negatively on staffing out of hours.
Must Do
St Thomas' Hospital
The service must ensure staff trigger staffing concerns promptly to ensure they are re-deployed to the area most in need, to keep women and babies safe.
Must Do
Frimley Park Hospital
The service should consider the addition of a supernumerary co-ordinator to oversee staff and acuity across the whole maternity unit effectively.
Should Do
Family Nurse Partnership & Health Visiting
The service should implement new tools and processes to enable effective reallocation of caseloads when staff members go on long-term leave or move job roles.
Should Do
Epsom General Hospital
The service must ensure medical staffing for maternity triage is reviewed so there are sufficient numbers of staff to review women and birthing people in a timely manner.
Must Do
Durham Diagnostics and Treatment Centre
The service should consider developing the clinic utilisation tool to identify and improve capacity for further clinics and avoid underuse of DDTC.
Should Do
Durham Diagnostics and Treatment Centre
The service should continue to develop the clinic utilisation tool to identify and improve capacity for clinics across all sites.
Should Do
Clifton Hospital
The trust should ensure the trust continues to review nursing and medical staffing within surgery so that the right people with the right skills are in the right locations.
Should Do
Clifton Hospital
The trust must ensure they deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure they can meet people’s care and treatment needs.
Must Do
Clifton Hospital
The trust must ensure the trust deploys sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure they can meet people’s care and treatment needs.
Must Do
Chesterfield Royal Hospital
The service should continue to monitor staffing levels to ensure all clinical areas are adequately staffed to provide safe patient care.
Should Do
Bridlington Hospital
The service must ensure that sufficient numbers of suitably qualified, competent, skilled and experienced registered nursing staff are deployed across the medicine wards on the Scarborough Hospital site to promote safe care and treatment of patients.
Must Do
Bridlington Hospital
The service must ensure that sufficient numbers of suitably qualified, competent, skilled and experienced medical staff are deployed overnight for medicine wards on the Scarborough Hospital site to promote safe care and treatment of patients.
Must Do
Whipps Cross University Hospital
The service should ensure that there is adequate skill mix and that there is always a supernumerary labour ward shift co-ordinator.
Should Do
HMICFRS recommendations(9)
FRS 2018-19 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: We have serious concerns about Northamptonshire FRS’s ability to respond to incidents. The service consistently doesn’t have available its minimum number of fire engines. Senior managers are not routinely told when this happens. Recommendation: The service should …
Recommendation
The policing response to antisocial behaviour: PEEL spotlight report
Renewed focus on resourcing neighbourhood police teams and recognising importance of their continual presence in communities
Recommendation
FRS 2018-19 CoC Recommendations: Surrey Fire and Rescue Service
Cause of concern: Surrey FRS doesn’t have a robust and sustainable system to support its operational response model. Recommendation: The service should ensure it understands and actively manages the resources and capabilities available for deployment.
Recommendation
The hidden victims: Report on Hestia's super-complaint on the police response to …
Ensure resources enable effective investigation of modern slavery offences with appropriately skilled investigators
Recommendation
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 September 2025, chief constables should, using the information collated by the NPCC lead under recommendation 21, consider whether and how dedicated stalking officers, staff, or subject matter experts can be used to support their force's response to stalking.
Recommendation
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 March 2025, the NPCC lead for stalking and harassment should collate and disseminate information to chief constables on the dedicated stalking co-ordination roles that exist across policing.
Recommendation
FRS 2018-19 CoC Recommendations: Surrey Fire and Rescue Service
Cause of concern: Surrey FRS doesn’t have a robust and sustainable system to support its operational response model. Recommendation: The service should ensure it has appropriate resources (people and equipment) available to respond to risk in line with its integrated …
Recommendation
FRS 2021-22 CoC Recommendations: Northumberland Fire and Rescue Service
Cause of concern: The management of dual contracts, for staff working on-call and wholetime in the service, must be improved. Recommendation: By 31 March 2022, the service should:- make sure staff take appropriate breaks between on-call and wholetime commitments for …
Recommendation
FRS 2018-19 CoC Recommendations: Buckinghamshire Fire and Rescue Service
Cause of concern: We have serious concerns as to whether Buckinghamshire FRS has the resources it needs to meet its foreseeable risk. As a result of the financial position the service finds itself in, it doesn’t have enough operational firefighters …
Recommendation
ICIBI immigration recommendations(6)
An inspection of Border Force operations at Stansted Airport
Recommendation 5 Ensure that sufficient “Roving Officers” are deployed at Stansted to discharge fully Border Force’s responsibilities for safeguarding passengers, both adults and children, in particular when 15 or more …
Inspection report of Birmingham Airport, February 2013
Partially Accepted - As the report notes, examination of customs resources was out of the scope of this inspection and ICIBI’s finding was based on a short onsite observation at …
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 1 Review the Stansted “staffing formula” and ensure overall numbers, including the “Seasonal Workforce (SWF)”, are sufficient to enable permanent staff to be released for skills training, and allow …
Inspection report on an interim re-inspection of family reunion, July 2017
Dedicate staffing resource to urgently address the work in progress (WIP), including the appeals WIP, prioritising applications from children separated from both parents.
An inspection of Border Force operations at Stansted Airport
Recommendation 1 Review the Stansted “staffing formula” and ensure overall numbers, including the “Seasonal Workforce (SWF)”, are sufficient to enable permanent staff to be released for skills training, and allow …
Inspection report on an interim re-inspection of family reunion, July 2017
To increase efficiency and streamline allocation of decisions, implement a mechanism to triage family reunion applications after biometrics have been submitted and before the decision-making stage.
PPO death in custody recommendations(9)
The Governor
The Governor should review the numbers of night orderly staff and consider stationing one or more assist night orderlies at the further end of the prison to minimise delays in entering cells at night.
The Governor
The Governor should ensure that the key worker scheme is properly embedded and that key workers are allocated sufficient time for an average of 45 minutes per prisoner per week for delivery of the key worker role.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that: • healthcare and prison staff communicate to ensure that prison staff understand which appointments are clinically urgent or essential; and • appropriate arrangements are in place to enable prisoners to attend …
The Head of Healthcare and the Governor (HMP Stafford)
The Head of Healthcare and the Governor must work together to ensure that security staff always liaise with healthcare staff to acknowledge healthcare priorities when there is not sufficient escort staff for all planned health appointments;
The Governor
The Governor should ensure that prisoners are promptly allocated a key worker, who is able to see them on a regular basis.
The Head of Healthcare, the Forensic Offender Mental Health Service …
The Head of Healthcare, the Forensic Offender Mental Health Service and Business Development Manager should implement a zoning system so that mental health staff can easily identify which prisoners are under their care and create appropriate treatment plans to meet …
The Head of Healthcare
The Head of Healthcare should ensure that: • mental health tasks are checked daily, clearly actioned and allocated to appropriate members of the team; • mental health services are prioritised and reallocated when staff leave the service; and • all …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review healthcare staff attendance and input at daily segregation reviews, to ensure safe and effective care.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that clinical staff are consulted whenever possible before a use of force and attend any unplanned use of force as soon as possible, especially where a prisoner has already experienced a medical …
IOPC learning recommendations(6)
Police response to an abandoned emergency call – Cleveland Police, March 2020
The IOPC recommends that Cleveland Police should implement a system to ensure that despatchers can easily inform the relevant control room staff where it is not possible to deploy resources to an incident. This system should alert relevant staff to …
Recommendation - Thames Valley Police, June 2020
The IOPC recommends that Thames Valley Police consider what measures can be taken to improve Contact Management Centre resilience and increase support to staff; with particular regard to the practice of “patching together” Local Policing Area desks. This follows a …
Failure to investigate indecent exposure – Metropolitan Police Service, February 2021
The IOPC recommends that the Metropolitan Police Service (MPS) ensures that its call handlers are aware that they have discretion when assigning the length of time slots for police officers to attend car appointments for allegations of sexual offences. This …
Police investigation into serious sexual offences – Cambridgeshire Constabulary, July 2019
The IOPC recommends that Cambridgeshire Constabulary ensure that detectives working in the Paedophile Online Investigation Team (POLIT) carry a workload appropriate to their circumstances. This follows an IOPC investigation in which a part-time detective within POLIT was allocated two cases …
Recommendations - Kent Police, November 2020
The IOPC recommends that Kent Police should take proactive steps to improve oversight of the work carried out by PCSOs and introduce measures to ensure their work is recorded more effectively. An Inspector of the Maidstone Community Safety Unit has …
Investigation into the West Yorkshire Police response to reports of injuries to …
The IOPC recommends that West Yorkshire Police ensures that it is able to adequately resource the supervisory responsibilities in the safeguarding unit, taking into account both the number of people required and their levels of training and experience. This follows …
NAO audit recommendations(11)
Department for Work and Pensions Annual Report and Accounts 2020-21
Factor in fraud and error in its resourcing decisions. The Department should consider the fraud and error impacts in its supply and demand modelling for staffng levels, so that it can demonstrate that it has achieved the value-for-money level of …
Accepted
Managing central government property
g) The OGP should: ? support departments to improve maturity of property skills; and ? monitor departments? level of skills against the functional standard to ensure they are being met across government; collect data on the impact and benefits of …
Accepted
Managing central government property
d) The Cabinet Office should work with departments to prepare workforce plans for the next five years. These plans should then be consolidated to produce a single view of workforce plans by year and region.
Accepted
Managing central government property
b) analyse the plans for each portfolio by location to identify any duplication and understand where efficiencies can be achieved. It should track the actions taken and monitor the savings that are made across government as a result of its …
Accepted
Managing central government property
a) ensure each property portfolio has an identified single lead by December 2022. The lead should have clear responsibilities and objectives related to their portfolio and provide a consistent set of information to support central oversight; and
Accepted
Driver & Vehicle Licensing Agency Annual Report & Accounts 2021-22
We recommend that the DVLA renew its efforts to maximise the impact its devolved partners can have on VED enforcement, based on existing powers.
Accepted
Driver & Vehicle Licensing Agency Annual Report & Accounts 2021-22
In respect of the specific enforcement activities ? prosecutions and out-of-court settlements ? that remain significantly below pre-pandemic levels, we recommend that the DVLA review its targets and the measures needed to achieve them, both within the DVLA and in …
Accepted
The government’s approach to test and trace in England – interim report
c) set out a clear strategy for how national and local tracing teams will work together, informed by a good understanding of local authority capacity and performance. The number of local authority-run schemes is set to increase, and NHST&T needs …
Rejected
The government’s approach to test and trace in England – interim report
We highlight here the most significant risks and issues that NHST&T needs to address in the immediate future. It should: a) explore how to make fuller use of its theoretical maximum testing capacity each day, so that existing infrastructure and …
Partially accepted
HS2: update following cancellation of Phase 2
HS2 Ltd should: complete its organisational changes and monitor how well the changes are effectively supporting it to manage the revised programme.
Accepted
Tackling serious and organised crime
The Department and the NCA should build on initial work to agree a more efficient way to distribute and share capabilities across government and law enforcement bodies. Capabilities have been inconsistently developed and often unnecessarily duplicated across bodies. The Department …
Partially accepted
IMB individual recommendations(42)
Hindley (2023)
The Board is concerned about occasions when there is a necessary change of regime and/or staffing shortages, that specialist activity is often the first casualty. For example, key work sessions or specialist activity personnel are often redeployed onto general operational duties. Under such circumstances the reducing violence coordinator is often moved to operations and any scheduled key worker sessions are …
Governor / Director
Deerbolt (2023)
While acknowledging the need to support establishments across the country, how will HMPPS ensure that staffing levels and site-specific demands are considered before assigning staff to other locations? Will the focus be on enabling each site to maintain a full operational regime rather than mandating a percentage of staff to be sent on detached duty, potentially compromising the functioning of …
HMPPS
Implemented
Deerbolt (2024)
How will HMPPS ensure that staffing levels and site-specific demands are considered before assigning staff to other locations? Will the focus be on enabling each site to maintain a full operational regime rather than mandating a percentage of staff to be sent on detached duty, potentially compromising the functioning of the sending establishment?
HMPPS
Exeter (2020)
Will the Governor undertake to improve the priority given to key worker activity and ensure that key workers are given the time to perform their role rather than being allocated to other duties? (See paragraph 5.3).
Governor / Director
Bristol (2020)
Her Majesty’s Prison and Probation Service (HMPPS) needs to ensure sufficient resource job profiling to allow key work to take place. As soon as there is a resource shortage, key work is the first thing to suffer, and the Board is already seeing evidence of this as the EDM level is reduced. Given the benefits seen of improved staff/prisoner relationships …
HMPPS
In Progress
Heathrow Immigration Removal Centre (2021)
Given ongoing recruitment challenges faced by the DET, consideration should be given to using alternative resources, such as the contractor, to provide some services currently the responsibility of DET but which they appear unable to deliver.
Ministry of Justice
Foston Hall (2022)
The high number of regime curtailments due to staffing issues (see paragraph 6.5.2)
Governor / Director
Wealstun (2023)
To consider that when approval has been given to over recruit, the number of officers to go on detached duty should be calculated after the non-effectives (at college, long term sick) have been deducted thus enabling full regimes and key working to be delivered.
HMPPS
Noted
Lewes (2023)
Will the prison service review the staffing budget in prisons and stop the practice of including non-effective staff in staff numbers?
HMPPS
Dartmoor (2023)
The increase in the population at HMP Dartmoor has not led to a matching increase in staff and support services. This has led to key weaknesses in purposeful activity, as identified in the recent HMIP report. While 65% of in-scope prisoners are in work/education, not all roles are full-time, many being half-time or part-time. As a result, only 41% of …
HMPPS
Downview (2025)
Can the Governor please comment on the issues raised earlier in this report regarding the effectiveness of certain staff in resolving prisoners’ basic issues, and on operational oversight in the prison generally?
Governor / Director
Noted
Cardiff IMB (2025)
Sut gall Bwrdd Iechyd Prifysgol Caerdydd a'r Fro weithio gyda Charchar Caerdydd a'r adran gofal iechyd i liniaru'r effaith y mae anfon carcharorion allan i'r ysbyty yn ei chael ar staffio’r carchar a'r drefn, o ystyried yr angen cynyddol am hebryngwyr?
NHS / Healthcare Provider
Cardiff (2025)
How can Cardiff and Vale University Health Board work with HMP Cardiff and the healthcare department to mitigate the impact that sending prisoners out to hospital has on prison staffing and the regime, given the increased need for escorts?
NHS / Healthcare Provider
In Progress
Wealstun (2020)
Ensure that when lockdown restrictions are lifted, key workers are fully in place for all prisoners (see paragraph 5.3.5).
Governor / Director
In Progress
Lincoln (2020)
There is still a concern that the prisoners allocated to kit distribution are underemployed (see paragraph 10.8).
Governor / Director
Bullingdon (2020)
How will the governor ensure that the new offender management in custody (OMiC) model is fully implemented, and that key workers will have sustainable caseloads and the capacity to meet with prisoners for the required length of time (see below, 4.3.9)?
Governor / Director
Wealstun (2021)
Ensure that when lockdown restrictions are lifted, key workers are fully in place for all prisoners (repeat area from 2019/2020 report) (para 5.3.6 refers).
Governor / Director
Woodhill (2022)
To review the impact of the current staffing levels on prisoners’ lives and develop innovative responses to mitigate these.
HMPPS
In Progress
Kirkham (2022)
The IMB is concerned that, whilst staffing is at a high level and the number of prisoners remains relatively low, various activities, including gym, C2W and the mail room, have been curtailed due to staff being redeployed to operational duties, such as escorts and checks on potential employers.
Governor / Director
Highpoint (2022)
Although the offender management team is efficient and hardworking, the allocated staffing levels result in high caseloads. This inevitably impacts the services and support provided for prisoners.
HMPPS
Wormwood Scrubs (2023)
Staff shortages are often given as a reason for cancelling out of cell activities. What action can be taken to address ‘on the day’ staff shortages more effectively?
Governor / Director
Liverpool (2023)
Staff absence is still an issue at HMP Liverpool, affecting daily staffing levels and resulting in frequent regime closures for prisoners. What action will the Prison Service take to directly reduce staff absence at HMP Liverpool and eliminate regime closures due to low staffing levels?
HMPPS
In Progress
Wandsworth (2025)
Although the prison was fully staffed, every day around one-third of staff were not available. What is being done to address this chronic issue and the impact it has on the regime?
Governor / Director
Oakwood (2025)
Can the Director review again whether there are sufficient resources to manage the internal movement of property?
Governor / Director
Leyhill (2025)
Steps be taken to speed up the work and enhance the efficiency of the community offender managers (COMs) in the external Probation Service, whose workload has increased significantly due to the implementation of the various early release schemes.
HMPPS
In Progress
Winchester (2020)
Will the Governor ensure that runners and escorts are reliably available to enable healthcare staff to deliver the required provision (see sections 3.2 and 6.2)?
Governor / Director
Maidstone (2020)
Work to reduce staff absence and implement OMiC effectively (see paragraphs 3.7 and 7.4).
Governor / Director
In Progress
Birmingham (2020)
The improved safety during lockdown is likely to be lost if staffing levels remain unchanged. Increased staffing during ‘step-in’ has proved to be the transforming impact of a better staff/prisoner ratio. Will the ratio of staff to prisoners be revised upwards, to ensure that more landing officers are available after the COVID-19 lockdown?
Ministry of Justice
Rejected
Winchester (2021)
Can the prison service prioritise and reduce the extra policy initiatives and tasks, such as those examples given in Section 3.1, that it expects senior prison staff to action, to give them more time to concentrate on progress at HMP Winchester? (See Section 3.1).
HMPPS
Noted
Gartree (2021)
Can confirmation be given as to when the key worker scheme will revert to the initial planned level, whereby all prisoners have a named key worker, who has time allocated for key worker duties, and that key workers will remain constant even when prisoners transfer within the prison?
Governor / Director
Exeter (2021)
Improve the arrangements for external seconded and temporary SMT cover so that there is time for the seconded person to share their expertise, make an impact, and be involved in embedding improvements etc., before they are moved on, which often creates additional turbulence within existing staff roles.
HMPPS
Morton Hall (2022)
extending the contract for librarian services to provide absence relief cover, avoiding the need to close the library and rely on the trolley service (see paragraph 7.1.3)
Governor / Director
Bedford (2022)
We echo the view of HMIP that the reallocation of gym staff should be a last resort.
Governor / Director
Oakwood (2023)
As noted in Section 5.3, the number of key worker sessions delivered during the reporting year was significantly below target. Can the Director consider setting targets, which are more realistic? Is the Director confident that key worker resources are sufficient to meet targets going forward?
Governor / Director
New Hall (2023)
There are concerns over the number of new trainee officers allocated to the prison, which are not funded and above the staffing requirements resulting in prison being subject to detached duty.
HMPPS
Drake Hall (2023)
Transferring women from other prisons to Drake Hall on Friday evenings, when there is only minimal staff cover, should not happen.
HMPPS
Sudbury (2024)
Continued late arrivals of prisoners after usual working hours continues to be an issue. How does the Prison Service plan to encourage prisoner escort contractors to improve this situation?
HMPPS
In Progress
Lowdham Grange (2024)
What permanent action is being taken to increase staff numbers of experienced prison officers and managers, to reduce the adverse impact of a shortage of both prisoner-facing and administrative staff on prisoner outcomes?
Governor / Director
In Progress
Kirkham (2021)
Kirkham are currently utilising a diversity and inclusion manager from HMP Preston on an 11-hour weekly contract. This is clearly insufficient and it is recommended that funding is made available to support a Kirkham-based post.
Governor / Director
Kirkham (2021)
The Board feels that the SMT and senior management were not operating in a cohesive manner. We are aware that the introduction of a new Governor will go some way to addressing the issues.
Governor / Director
Bedford (2021)
Over a quarter of health appointments were missed because the prison was unable to deliver prisoners to the healthcare area, which is both a waste of healthcare resources and really unhelpful for prisoners.
Governor / Director
Wetherby (2023)
A noticeable factor in successful and efficient departments at Wetherby seems to be consistency of staffing. The Board notes that staffing changes at all levels continue to occur frequently. Can the Governor assure the Board that staff changes will be kept to a minimum?
Governor / Director
Health investigations(130)
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 4
The Trust should continue implementing New Ways of Working (NWW) in all acute wards to ensure an effective full daily multidisciplinary team (MDT) review of all patients‟ care and treatment. In order to achieve this the MDT will also need to: be subject to a full skill mix review which …
north_west
Independent investigation: Katie Kazmi, Reading (1999) — Rec 12
Trusts should ensure that there is an adequate administrative support system for CMHTs.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 7
Social services and trusts should ensure that there is an adequate administrative support system for CMHTs.
south_east
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (viii)
The Trust should carry out a general review of the functioning of the Out-patient Clinic for the purpose of achieving an equitable distribution of the workload between the senior and junior psychiatrists.
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.2.h
CMHTs Forensic ASWs or other specialist professionals working with mentally disordered offenders who work with or for CMHTs should have dedicated time allocated in order to deal with and develop links with MAPPA organisers.
london
Independent investigation: Gwen Poole, Llanbradach, Caerphilly (2009) — Rec 3.20
Aneurin Bevan Health Board and Caerphilly County Borough Council should ensure that the Caerphilly Assertive Outreach Team is adequately resourced to provide a service seven days a week where needed.
wales
Independent investigation: Warren Duke, Slough (but Tees patient) (2015) — Rec Recommendation 3
TEWV must review the TEWV EIPT job plans to ensure consistent medical input to the team.
north_east_yorkshire
Independent investigation: Trevor Spencer, Dagenham — Rec R6
The trust should review processes for the allocation of care coordinators to ensure that the skills, competencies and experience of the coordinator are appropriate to the needs of the service user.
london
Independent investigation: Sharon Wall, Gloucester — Rec 8.3
The second recommendation is for the Trust to review the structure of the staffing arrangements to ensure that an appropriate balance of trained and untrained, senior and junior staff is available to deliver the best quality of safe care in what is a very challenging environment. We will follow this …
south_west
Independent investigation: Rae Torbet(Ms E), Hastings, Sussex (2003) — Rec 9.9.2
that a care coordination system is systematically implemented which clarifies the role.
south_east
Independent investigation: Rae Torbet(Ms E), Hastings, Sussex (2003) — Rec 9.1.5
That a clearer process is established for the allocation and coordination of each case.
south_east
Independent investigation: Phyllis Deane, Shaldon/Torquay Devon (2007) — Rec 7
The workload of consultant psychiatrists should be regularly monitored to ensure that they are not being spread too thinly across too many areas of responsibility. This should be linked to the Clinical Audit Programme and routinely reviewed.
south_west
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 11
The trust should consider a review of the caseload and staffing levels in the Croydon Forensic Team. (DB)
london
Independent investigation: Peter Freeman, Newton Abbott (2019) — Rec Recommendation One
The Trust must provide assurance that when staff in psychological therapies are transitioning between roles there is a formal review of clinical caseload, and the practitioner’s job plan reflects their workload and commitments.
south_west
Independent investigation: PC Johnathan Henry, Luton (2007) — Rec (Trust) Recommendati
Review team caseloads annually and ensure team managers review care coordinator workloads on a monthly basis.
east_of_england
Independent investigation: Natasha Wild, Rochdale (2016) — 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
Independent investigation: Marie Harding, Worthing (2004) — Rec R5
We recommend a review of the criteria used when allocating care coordinators. They should be allocated against objective criteria such as their experience, case load and the complexity of the case to be managed. The review should also consider what additional supervision is required when recently qualified professionals are appointed …
south_east
Independent investigation: Lesley Wright, Tooting (2006) — Rec R10
The trust should ensure that managers allocate cases in a timely way after a request from a GP for an urgent assessment under the MHA.
london
Independent investigation: Lesley Wright, Tooting (2006) — Rec R6
The trust should ensure that operational managers monitor the impact of sickness absence and take action to minimise its effect on the functioning of CMHTs.
london
Independent investigation: Kyle Maher, Tooting (2017) — Rec R1
The trust should have a system in place to ensure that the care coordinators within the EIS hold caseloads within the current national recommended number (no more than 15) to promote effective support to service users.
london
Independent investigation: Kenneth Auger, Merthyr Tydfil (2008) — Rec 3.4o
Review the function and model of its CRHT, ensuring that the Home Treatment and Crisis Team staff are not split in their function.
wales
Independent investigation: Keith Robinson, Scartho (2017) — Rec 4
NAViGO must consider the appropriate guidance and provide assurance that when reviewing CMHT Consultant Psychiatrist job plans that time in the CMHT is reliable and consistent.
north_east_yorkshire
Independent investigation: Karina Menzies, Cardiff (2012) — Rec 4c
Ensure that all case loads are routinely reviewed and audited to ensure their manageability as per the guidance documents referenced in paragraphs 3.6 and 3.9 in order to identify where individual case loads are excessive. Appropriate action should then be taken to address any issues that emerge.
wales
Independent investigation: Julie McKinley, Finsbury Park (2009) — Rec 9
Management of Frontline Services during periods of Change – From January 2009 the Short Term Assessment and Recovery Team (START) (the gatekeeper to the whole of the local mental health services) underwent a number of major alterations and reconfigurations with significant changes in staff. During this period there were a …
london
Independent investigation: John McGrath, Stapleford, Nottingham (2009) — Rec 2
If the current model of AO is to continue in Nottinghamshire, it is essential that there is an increase in the provision for dedicated medical sessions to the County South AO Team. This investigation, and the Trust’s own investigation, identified insufficient medical sessions provided to this AO Team. This means …
midlands
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R7
Consideration should be given by the trust to having a non-medical individual with the requisite seniority, such as ward manager or senior occupational therapist chair the Monday management meeting, CPA reviews or ward rounds.
london
Independent investigation: Jim Ward, Ayr (2007) — Rec 18
SWD1 must put in place a system where staff absence does not result in cases being left for prolonged periods without review or intervention.
scotland
Independent investigation: Jean RobinsonDerek RobinsonKevin Molloy, Highgate/Tottenham (2004) — Rec R5
We recommend a review of the criteria used when allocating care coordinators. They should be allocated against objective criteria such as their experience, case load and the complexity of the case to be managed. The review should also consider what additional supervision is required when recently qualified professionals are appointed …
london
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 53
Allocation of individual patients should take full note of the difficulty of the case and the level of experience of the nurse.
midlands
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 4
That "associate nurses" be appointed for each patient so as to ensure continuity of care over the three shifts and during other absences of the "named nurse".
midlands
Independent investigation: Eric Daggers, Croydon (2005) — Rec 18
Criteria should be developed or reviewed to ensure consultants and other senior members of staff take a more active role in the care and management of patients with complex issues. (II/AA)
london
Independent investigation: Eric Daggers, Croydon (2005) — Rec 11
The trust should consider a review of the caseload and staffing levels in the Croydon Forensic Team. (DB)
london
Independent investigation: Edward Miles, Tower Hamlets (2003) — Rec 1
The Trust must ensure that all consultants working in Tower Hamlets are fully integrated into the community mental health teams. This must include regular attendance at team meetings, supervision of junior doctors and other staff, and active involvement in the day-to-day care of patients. The Trust must monitor the attendance …
london
Independent investigation: Daniel Quelch, Maidenhead, Berks (2007) — Rec R1
We recommend that the trust considers issuing guidance on how the particular skills of recovery team members are matched to clients when allocating care coordinators.
south_east
Independent investigation: Claire Wilson (& unborn baby), Grimsby (2009) — Rec R5
NAViGO should ensure psychologists‟ case loads and job plans are appropriate and reviewed on a regular basis. [see paragraph 8.31, 8.106]
north_east_yorkshire
Independent investigation: Chloe Fahey, Manchester (2003) — Rec H.1
It is recommended that, where required, job share arrangements with shared responsibility for cases, rather than part time arrangements, are used for employment of workers managing people on enhanced CPA.
north_west
Independent investigation: Chloe Fahey, Manchester (2003) — Rec G.3
It is recommended that each CPA review consider whether the current care coordinator/care manager is still best placed to service the client and whether any additional professionals need to be brought in.
north_west
Independent investigation: Caroline Evans, Llangadog, Camarthen (2003) — Rec 8.4.20
Funding arrangements should be put in place to ensure that PRISM is able to cover critical holiday periods such as Christmas.
wales
Independent investigation: Caroline Evans, Llangadog, Camarthen (2003) — Rec 8.4.11
The medical on call cover system should be strengthened and formalised in order that there are clear cover arrangements and formal handover for staff on leave, including accessibility to all clinical notes. Staff off-duty or on leave should have cover which will embrace at some point in the chain a …
wales
Independent investigation: Carl Scott, Winchester — Rec 2
The CMHT to focus on how they use the resources they have for their higher risk patients. This is in the context of the Trust-wide dependency and acuity review currently being carried out by the Trust, which is intended to enable the Trust to understand the staffing resources they have …
south_east
Independent investigation: Camille Remy (pregnant), Hackney (2006) — Rec R6
BEH NHS trust should keep the patient numbers of individual medical staff under review to ensure that they are at all times manageable and allow staff to fulfil their professional obligations, including allowing them to have an appropriate grasp of the issues relating to their patients.
london
Independent investigation: Joe Lewis, Brighton (2014) — Rec 2
The Trust must ensure that team managers have arrangements in place to re-allocate the caseload of a team member who is not at work for an extended period of time. The Trust must also implement a system to monitor compliance with this and take necessary steps to remedy non- compliance.
south_east
Independent review into treatment and care provided by 2Gether NHS … — Rec 2
The second recommendation is for the Trust to review the structure of the staffing arrangements to ensure that an appropriate balance of trained and untrained, senior and junior staff is available to deliver the best quality of safe care in what is a very challenging environment. We will follow this …
X’ was an inpatient at 2Gether NHS Mental Health Foundation Trust. The 2Gether NHS Foundation Trust
south_west
*Independent investigation into the care and treatment of Patient 2009/3245: … — Rec 1
The panel were encouraged to hear at interview that steps had been taken by the Trust to ensure transparency of multiple concurrent projects following the introduction of an overview project framework. However, the inquiry believes that the effectiveness of practitioners’ workloads being monitored is also essential in both supporting and …
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Accepted
Independent investigation into the care and treatment of Christopher Stone-Houghton … — Rec 1
The CRHTT should review their system of patient allocation to ensure that patients are supported to develop a therapeutic alliance with allocated staff, and that patient’s needs are matched with staff with the appropriate skills.
Hampshire and Isle of Wight Healthcare NHS FT
south_east
An independent investigation into the care and treatment of Mr … — Rec Recommendation One
The Trust must provide assurance that when staff in psychological therapies are transitioning between roles there is a formal review of clinical caseload, and the practitioner’s job plan reflects their workload and commitments.
Devon Partnership NHS Trust
south_west
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
An independent investigation assurance review (published June 2021) can be … — Rec 4
NAViGO must consider the appropriate guidance when reviewing CMHT Consultant Psychiatrist job plans to ensure that time in the CMHT is reliable and predictable.
north_east_yorkshire
This Independent Investigation into concerns and issues raised relating to … — Rec 8
The Trust should implement a clear and consistent approach to job planning for all Consultant Urologists, ensuring that job plans accurately reflect clinical responsibilities, administrative duties, and on-call commitments, and that they are regularly reviewed and agreed.
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
Independent investigation into the care and treatment of Ms A — Rec 19
The Trust should review their Duty Dr on-call arrangements to consider the use of a specific Dr on-call rota for the Forensic services.
Ms A who committed a homicide in October 2011. Ms A was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Scottish Fatal Accident Inquiries(1)
Article 2 learning points(4)
— LP 9
We further recommend that Holloway agrees a minimum staffing level and takes action when the level in any area and/or at any time is not reached.
The Governor
Accepted
— LP 8
We recommend that the adequacy of staffing levels is reviewed particularly in respect of the needs of women at weekends. We also recommend that stronger efforts are made to ensure residential units are not deprived of staff because of bed watches.
HMPPS
Accepted
— LP L
Greater priority should be given to ensuring that prisoners with open ACCTs are allocated to a Personal Officer who attends or reports to all ACCT reviews.
HMPPS
Rejected
— LP K
Either higher priority should be given to case management or more realistic Guidance about ACCT Case management needs to be produced. There should be continuity of Case Manager in ACCT reviews, with consideration given to whether a review deadline might be relaxed if that permits a Case Manager to attend, …
HMPPS
Rejected
Detention investigations(14)
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R12
Managers undertaking the current staffing review should in particular consider and address weaknesses in the night staffing arrangements.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R11
Managers should undertake an audit and assessment of the roles that only female staff should undertake and how many female staff are required at Yarl’s Wood to answer the needs of residents. Managers should develop a staffing plan, based on that audit and assessment.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R10
Managers undertaking the current review of staffing should rectify the problems with management capacity.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 1
GSL reviews deployment of staff to incidents and the use of ‘talk through’ mode on the radio allowing officers to self deploy.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 44
I recommend that all casework currently undertaken by the contract monitor be assigned elsewhere.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 2
I recommend that the staff of Green Shift be dispersed equally amongst the other shifts.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R9
Managers undertaking the current staffing review should address the question of how staff can best be given time to engage with residents and meet their emotional as well as practical needs.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R3
G4S managers should work with DCMs undertaking training to ensure a common understanding of requirements of that training and how much time DCMs will be given away from operational duties as study leave. (To be completed within 3 months)
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 16
I also recommend that, wherever possible, staff are promoted into a different shift from the one in which they have worked as a DCO.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R4
Serco should consider with the Home Office whether the escort service can take responsibility for ensuring that residents are presented to HOIE for removal. This would include escorting residents from their room in Yarl’s Wood.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 53
I recommend that a separate resource is identified and properly trained to handle complaints and associated work.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 27
I recommend that IND reviews the relationship between escort contracts and removal centre contracts with a view to building in contractual requirements relating to timely presentation of detainees for escorts.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 12
I recommend that the Race Relations Liaison Manager’s office be re-located in the main compound and that the remit for the postholder should emphasise that they must spend more time out and about.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 17
I recommend that the senior management offices be re-located at the heart of the compound.
Immigration Detention
Independent reviews(50)
Ockenden Review — Rec LAfL 14.2
Improving Management of Patient Safety Incidents The Trust executive team must ensure an appropriate level of dedicated time and resources are allocated within job plans for midwives, obstetricians, neonatologists and anaesthetists to undertake incident investigations.
Health & Social Care
National workload action group: reports on social worker workload — Rec 1
Stakeholders, including the Department for Education (DfE) and the regulators, should work together to produce guidance which clearly differentiates between the desk-based activities essential for social workers to complete and the administrative tasks that can be completed by others or automated.
Health & Social Care
Carter NHS Productivity Review — Rec 2
NHS Improvement should develop and implement measures for analysing staff deployment during 2016, including metrics such as Care Hours Per Patient Day (CHPPD) and consultant job planning analysis, so that the right teams are in the right place at the right time collaborating to deliver high quality, efficient patient care.
Health & Social Care
Litchfield WCA Review Year 4 — Rec 20
Re-engineer the case mix for the two levels of Decision Maker so that more senior staff consider "borderline" cases (e.g. 6 – 21 points) and more junior staff process all others.
Employment & Work
Willis Commission on Nursing 2012 — Rec 4
The numbers and roles of healthcare support workers who deliver patient care must be properly planned and regulated, in the interests of patient safety and care quality.
Health & Social Care
Willis Commission on Nursing 2012 — Rec 1
Evidence of the positive impact of registered nurses on patient outcomes must be utilised by healthcare providers in planning the nursing skill mix.
Health & Social Care
Cavendish Review — Rec 17
NHS England should include the perspective of HCAs and support workers in its review of the impact of 12-hour shifts on patients and staff.
Health & Social Care
Flanagan Review of Policing — Rec 31
ACPO, the APA and the NPIA should develop a broad set of principles for minimising abstraction from neighbourhood policing teams by April 2008. These should be adopted by all forces no later than June 2008. Progress will be reviewed in.
Policing & Security
Flanagan Review of Policing — Rec 29
Chief constables and senior community safety partners should ensure that effective leadership, tasking and direction of neighbourhood resources are vested in the most appropriate individual, irrespective of the organisation for which the individual works.
Policing & Security
Flanagan Review of Policing — Rec 7
Forces should review their demand profiles, taking account of more detailed information now available, to ensure that resources are deployed to areas of greatest risk and priority. HMIC should use this information in inspections from 2009-10.
Policing & Security
Calvert-Smith SFO Review — Rec 9
The SFO must ensure it has an effective system to support and monitor resourcing across all cases. Individual case resources must be clearly determined and subject to regular review and assessment by Heads of Division and Case Controllers with oversight by General Counsel and the COO. Written detailed case resource …
Justice & Legal
Kerslake Review — Rec 16
Greater Manchester Police should develop sufficient senior-officer capacity and capability to ensure that single officers are not required to manage multiple strategic roles simultaneously during major incidents
Policing & Security
Accepted
Darzi Review — Rec 28d
Drive productivity in hospitals. Acute care providers will need to bring down waiting lists by radically improving their productivity. That means fixing flow through better operational management, capital investment in modern buildings and equipment, and re-engaging and empowering staff.
Health & Social Care
Darzi Review — Rec 13
The NHS budget is not being spent where it should be — too great a share is being spent in hospitals, too little in the community, and productivity is too low. Hospitals are where most waiting list procedures take place. But they present an apparent paradox. Growth in hospital staff …
Health & Social Care
Youth Justice Board Review — Rec 10
The YJB should review its senior staffing structure, in line with the overall recommendations of this report, making any changes required in response to the changes recommended in this report.
Justice & Legal
National workload action group: reports on social worker workload — Rec 13
DfE should work with DHSC and with social worker employers to understand more about the ‘office space’ needs of the child and family workforce, and the impact of ‘hot desking’ and other non-standard office space arrangements on individuals, teams and the professional identity of the social worker workforce.
Health & Social Care
Owens Review — Rec 20
That HMPPS and the Ministry of Justice examine the balance between the operational model within prison establishments and what resources are based centrally or regionally. The aim should be that to: Not replicate services with the Ministry of Justice (department). To maintain nationally or regionally the HMPPS specialist services that …
Justice & Legal
Narey-Owers Foster Care Review — Rec 7
Our conclusion is that, despite the commendable commitment of some individuals, there is little to recommend the IRO role and believe local authorities should be allowed to dispense with the role; re-investing savings in front line staffing.
Other
Narey-Owers Foster Care Review — Rec 6
We suggest that local authorities should decide which individual social worker is best placed to offer the support to the foster family in long-term placements. As well as resulting in a welcome reduction in family intrusion, and sometimes confusion, this change would deliver cost savings to hard-pressed local authorities. But …
Other
Levene Defence Reform Report — Rec 12
Key recommendation 12. The Department should manage and use its senior military and civilian personnel more effectively. With oversight of the ‘Appointments’ sub-committee to the new Board, the career management system should be designed so that individuals stay in key senior posts for longer and the processes for promotions and …
Other
Levene Defence Reform Report — Rec 11a
The Department should reduce the size of the senior cadre of Defence and the management levels below it. To enable this, the Department should review all non-front line military posts from OF5 (Captain / Colonel / Group Captain) and civilian posts from Band B (Grade 7), to determine the need …
Other
Levene Defence Reform Report — Rec 11
Key recommendation 11. In line with the overall capability planning and financial management model, the Department should afford greater priority to managing its ‘human capability’ as a strategic resource, to ensure a better balance with its consideration of equipment capability. Specifically, it should develop the ‘Whole Force Concept,’ which seeks …
Other
Litchfield WCA Review Year 4 — Rec 26
The Department carries out a full impact assessment on an alternative process whereby DWP Decision Makers triage cases; • DWP, rather than the HAP, issues the ESA50 and reviews the response with any supporting evidence supplied; • the Decision Maker determines (with the help of decision support materials) whether further …
Employment & Work
Willis Commission on Nursing 2012 — Rec 3
Graduate nurses, as leaders of clinical teams, should supervise and delegate work to 'registered healthcare assistants' with clearly defined roles.
Health & Social Care
Willis Commission on Nursing 2012 — Rec 2
Employers must make use of the enhanced skills of the emerging graduate nursing workforce, as an opportunity to drive up standards and provide effective leadership and supervision of the clinical nursing workforce.
Health & Social Care
Tooke MMC Inquiry — Rec 16
DH should recognise the burgeoning supply of medical graduates it has commissioned and make explicit its plans for the optimal use of their skills for the benefit of patients. It is recommended that sufficient numbers of Core Specialty training posts (see Recommendation 33) should be made available to accommodate doctors …
Health & Social Care
Roberts Review (STEM) — Rec 2.8
The Review is convinced that the high pupil-to-staff ratios in schools in England – particularly in practical classes – is having an adverse effect on the quality of pupils' science and D&T education, and in turn on the supply of science and engineering skills. The Review believes these high pupil-to-staff …
Education
Flanagan Review of Policing — Rec 13
The Home Office should set out its strategy for workforce reform in the forthcoming Green Paper, and the NPIA should facilitate the development of a ten-year workforce plan for the service. Both of these pieces of work should emphasise the importance of matching skills and aptitudes to roles and tasks.
Policing & Security
Flanagan Review of Policing — Rec 8
Forces should focus effort on ‘high potential’ areas for improved productivity, such as demand management (where QUEST has highlighted areas for improvement), procurement and flexible working. HMIC will be looking for evidence of using best practice in inspections from 2009-10
Policing & Security
Tickell Review of the EYFS — Rec 34
I recommend it is made clear in the EYFS that, when ratios are met and maintained across the whole provision within an early years setting, it is left to the professional expertise of staff, and the leaders and managers of settings, to work with parents and carers to agree exactly …
Education
Selous Review — Rec 81
All three Services to take steps to aid the retention of Serving personnel in dual-serving relationships, particularly those in different Services, and ensure that career managers liaise with each other to manage work requirements and deployments in order to minimise relationship stress.
Other
MacAlister Review — Rec 59
The government should introduce new national rules on agency usage supported by the development of not-for-profit regional staff banks to reduce costs and increase the stability and quality of relationships children and families receive.
Education
Modern Slavery Act Review — Rec 44
The Government should conduct further research into the optimum contact time between ICTA and child, and the optimum caseload per ICTA, to deliver a service that meets every child’s best interests. Caseload levels should be monitored by the Independent Anti-Slavery Commissioner and the Children’s Commissioners for England and Wales.
Justice & Legal
Accepted
Modern Slavery Act Review — Rec 43
Caseloads for each ICTA should be capped at a modest number to ensure regular contact and quality provision.
Justice & Legal
Accepted
Cass Review — Rec 13
To increase the available workforce and maintain a broader clinical lens, joint contracts should be utilised to support staff to work across the network and across different services.
Health & Social Care
Accepted
Youth Justice Board Review — Rec 15
The YJB to review the structure of its regional oversight team so that it has the right level of expertise, can assess performance, intervene where required, prioritise sharing best practice and drive continuous improvement.
Justice & Legal
National workload action group: reports on social worker workload — Rec 11
DfE, ideally in partnership with Department of Health and Social Care (DHSC), should commission further work to understand more about the impact of hybrid working on the social worker workforce.
Health & Social Care
Tickell Research Bureaucracy Review — Rec 17
Wherever possible, research organisations should examine the feasibility of delegating research-related approvals to research managers and officers who are closer to research.
Other
Levene Defence Reform Report — Rec 10
Key recommendation 10. Enabling services should be delivered as efficiently, effectively and professionally as possible, including through the creation of the new Defence Infrastructure and Defence Business Services organisations on which we advised the Defence Secretary earlier in the year.
Other
Heseltine Growth Review — Rec 88
Government should accelerate the pace at which it is tackling illegal immigration, overstayers and the backlog of residency applications. It should do this through a significant but temporary redeployment of public sector people and resource. The backlog should be tackled on a task and finish basis, with clear targets and …
Other
Heseltine Growth Review — Rec 8
At the earliest opportunity civil servants based across the country should be brigaded into Local Growth Teams, structured around clusters of LEPs, primarily tasked with joining up government and local partners in the areas of their responsibilities to facilitate, identify and realise economic opportunities.
Other
Young Health & Safety Review — Rec 34
Open the delivery of inspections to accredited certification bodies, reducing the burden on local authorities and allowing them to target resources at high risk businesses.
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
IOPC Review — Rec 84
The IOPC Director General should review planned savings to staffing costs, in light of the Review's observations. They should consider whether, as IOPC Hillsborough investigations conclude, its skilled investigators could be redeployed to wider operational work to backfill investigators lost through turnover, or arrest, or indeed reverse, the steep decline …
Policing & Security
IOPC Review — Rec 39
The IOPC should develop a workforce strategy in tandem with a revised estates strategy, future operating model and revised medium-term financial plan, to ensure human resources and financial planning are delivered effectively. The IOPC should review its fixed term contracts and temporary promotions within a revised workforce strategy.
Policing & Security
IOPC Review — Rec 34
The IOPC should consider what can only be done by the centre and what can be best delivered regionally. It should consider the feasibility of moving to a national operating model across its key operations, whilst preserving effective regional outreach. It should consider the place of the Metropolitan Police in …
Policing & Security
Maude Civil Service Review — Rec 26
Recommendation 26: all Senior Civil Service appointments, except at permanent secretary level, should be for a four year fixed tenure; and it should not be permissible for civil servants to apply for other jobs elsewhere in the Civil Service, or in central government organisations that are technically outside the Civil …
Other
Maude Civil Service Review — Rec 18
Recommendation 18: Senior officials in the functions in the departments should be directly employed by the central function, as is the case with the commercial function already. An immediate start should be made with the HR function.
Other
Farmer Review (Men) — Rec 15
Development of leaders and staff must support governors in fulfilling their Performance Agreement requirement to provide a staffing structure that makes family work an operational priority: • Given that family work has been characterised by unacceptable levels of inconsistency across the estate, the leadership capability strategy referred to in the …
Justice & Legal
Dash CQC Review — Rec 6
Recommendation 6: pause ICS assessments Given the difficulties to date in agreeing how best to assess ICSs, a need to ensure alignment with the NHS England Oversight Framework and considerable challenges within CQC, it is recommended that ICS assessments be paused for now with the nascent ICS assessment team redeployed …
Health & Social Care
LGO / SPSO decisions(13)
21-001-627 — London Borough of Enfield
Summary: Mr X complained the Council failed to remove stacked shipping containers near to his home. The Council was at fault for not taking the enforcement action it said it would. The Council will pay Mr X £300 for the avoidable time and trouble caused by having to complain and …
LGO (Local Government & …
Planning
Upheld
Jan 2022
22-002-513 — Birmingham City Council
Summary: Miss X complained that although she should receive an assisted collection service the Council repeatedly failed to collect her household waste and recycling on the scheduled days, despite collecting her neighbours’ waste. The Council’s the repeated failure to make regular household waste and recycling collections and return her bins …
LGO (Local Government & …
Environment And Regulation
Upheld
Oct 2022
22-002-234 — Birmingham City Council
Summary: Mr X complained the Council has repeatedly failed to collect his garden waste on the scheduled day, despite collecting his neighbours’ garden waste. Mr X has had to take the uncollected garden waste to the tip. The Council’s repeated failure to collected Mr X’s garden waste on the scheduled …
LGO (Local Government & …
Environment And Regulation
Upheld
Oct 2022
24-001-705 — South Tyneside Metropolitan Borough Council
Summary: We cannot investigate Miss X’s complaint about missed refuse collections resulting from strike action by the Council’s refuse collection crews. This is because the complaint is about an issue which affects all or most of the people in the Council’s area and the law does not allow us to …
LGO (Local Government & …
Environment And Regulation
Jun 2024
24-001-689 — South Tyneside Metropolitan Borough Council
Summary: We cannot investigate Mr X’s complaint about missed refuse collections resulting from strike action by the Council’s refuse collection crews. This is because the complaint is about an issue which affects all or most of the people in the Council’s area and the law does not allow us to …
LGO (Local Government & …
Environment And Regulation
Jun 2024
24-001-688 — South Tyneside Metropolitan Borough Council
Summary: We cannot investigate Miss X’s complaint about missed refuse collections resulting from strike action by the Council’s refuse collection crews. This is because the complaint is about an issue which affects all or most of the people in the Council’s area and the law does not allow us to …
LGO (Local Government & …
Environment And Regulation
Jun 2024
24-001-683 — South Tyneside Metropolitan Borough Council
Summary: We cannot investigate Mrs X’s complaint about missed refuse collections resulting from strike action by the Council’s refuse collection crews. This is because the complaint is about an issue which affects all or most of the people in the Council’s area and the law does not allow us to …
LGO (Local Government & …
Environment And Regulation
Jun 2024
24-001-672 — South Tyneside Metropolitan Borough Council
Summary: We cannot investigate Mr X’s complaint about missed refuse collections resulting from strike action by the Council’s refuse collection crews. This is because the complaint is about an issue which affects all or most of the people in the Council’s area and the law does not allow us to …
LGO (Local Government & …
Environment And Regulation
Jun 2024
24-001-669 — South Tyneside Metropolitan Borough Council
Summary: We cannot investigate Mrs X’s complaint about missed refuse collections resulting from strike action by the Council’s refuse collection crews. This is because the complaint is about an issue which affects all or most of the people in the Council’s area and the law does not allow us to …
LGO (Local Government & …
Environment And Regulation
Jun 2024
24-001-658 — South Tyneside Metropolitan Borough Council
Summary: We cannot investigate Miss X’s complaint about missed refuse collections resulting from strike action by the Council’s refuse collection crews. This is because the complaint is about an issue which affects all or most of the people in the Council’s area and the law does not allow us to …
LGO (Local Government & …
Environment And Regulation
Jun 2024
24-001-656 — South Tyneside Metropolitan Borough Council
Summary: We cannot investigate Mrs X’s complaint about missed refuse collections resulting from strike action by the Council’s refuse collection crews. This is because the complaint is about an issue which affects all or most of the people in the Council’s area and the law does not allow us to …
LGO (Local Government & …
Environment And Regulation
Jun 2024
24-001-655 — South Tyneside Metropolitan Borough Council
Summary: We cannot investigate Mrs X’s complaint about missed refuse collections resulting from strike action by the Council’s refuse collection crews. This is because the complaint is about an issue which affects all or most of the people in the Council’s area and the law does not allow us to …
LGO (Local Government & …
Environment And Regulation
Jun 2024
24-013-404 — Birmingham City Council
Summary: Ms X complained the Council has failed to provide a replacement pod for her recycled paper and cardboard despite first requesting this in June 2023. Ms X also complained the Council has failed to provide a replacement household waste bin. We found the delays in providing a replacement pod …
LGO (Local Government & …
Environment And Regulation
Upheld
Jun 2025
Domestic Homicide Reviews(52)— showing 50 strongest matches
Portsmouth — recommendation 14
In both Police and Probation services, domestic homicide reviews are dealt with by a central team whose role it is to compile IMR reports and liaise with review panels. This should be considered for health services so that professionals can retain their specialist focus where it is needed most, and …
Universal Health Services
Hackney — recommendation IPCC4
Staffing within Community Safety Units During its investigation the IPCC came to the conclusion that MPS Hackney borough CSU was left understaffed following the implementation of the LPM. It is recommended that the MPS ensures that it has processes in place to consider resourcing of domestic violence units is adequate …
Metropolitan Police Service
Metropolitan Police Service
West Berkshire — recommendation 3
Activity levels for both of the services should be set in line with capacity, and a staff skill mix set that is appropriate against the acuity and activity presented.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Kent — recommendation 15.
KDAC members must agree a process that ensures the IDVA who has the greatest knowledge of a case attends the MARAC meeting when it is discussed.
KDAC
Kent — recommendation 13.
ABC should consider nominating an officer who will attend the MARAC in the absence of the Housing Options Officer.
Town A Borough Council
Nuneaton and Bedworth — recommendation 13
Warwickshire Police ensure that the findings of the review of the police Referrals & Assessment Unit (RAU), which identified the need for better levels of supervision and processes to facilitate more efficient management of caseloads of staff, has been fully implemented, including: a. Development of a policy that identifies acceptable …
Warwickshire Police
Warwickshire Police
Nuneaton and Bedworth — recommendation 12
Warwickshire Police review the investigative decision-making process relating to ‘high risk’ domestic abuse incidents, to ensure that the appropriate level of skill and type of resources and supervision is allocated to each specific Domestic Abuse investigation.
Warwickshire Police
Warwickshire Police
Nuneaton and Bedworth — recommendation 7
Warwickshire County Council, as the commissioner of domestic abuse services, completes a review of the IDVA service to ensure that resources are maximised and deployed effectively to adequately support high risk victims across the County. This should include exploring alternative, flexible models of multi-agency support. The findings of the review …
Warwickshire County Council
Warwickshire County Council
Wiltshire — recommendation R74
BGSW CRC to consider the timing of cases being re-allocated. A 3-way to be prioritised if a re-allocation can not be avoided.
BGSW CRC
Nottingham — recommendation Equation 3
Caseworkers to be reminded/encouraged to cover work on each other’s cases when the caseworker is not available to ensure no unnecessary gaps in service delivery.
Equation
Lincoln — recommendation 10.4.5
Adult Care should ensure that effective measures are in place to determine the nature and complexity of cases and ensure that cases are allocated to staff with the appropriate experience and skills to manage them.
Lincolnshire County Council Adult Care
Croydon — recommendation AF
The Croydon Home Treatment Team to implement a clear system of task assignment and oversight arising from Clinical Review meetings to ensure that there are no delays in the completion of tasks
South London and Maudsley NHS Foundation …
South London and Maudsley …
North Yorkshire — recommendation North Yorkshire Poli
North Yorkshire Police should review the decision to appoint only police staff to the role of DAO. The IMR author believes a more blended mix of experiences would give a more comprehensive service to victims.
North Yorkshire Police
North Yorkshire Police
Wiltshire — recommendation 4
Staffing levels within the Intelligence Department are reviewed to enable stop and search forms to be inputted.
Wiltshire Police
Wiltshire Police
Newcastle-Under-Lyme — recommendation c
Operational Communications Department managers ensure that ACR positions are adequately staffed to ensure operator efficiency.
Staffordshire Police
Staffordshire Police
Bristol — recommendation Action for Children
In light of the above and other information, the Operational Director of Children’s Services and Children’s Services Manager should investigate the workload levels for practitioner staff and report on this and any action needed to the UK Director for Children’s services (West) and ensure that the Head of Safeguarding is …
Action for Children
Harrow — recommendation 4
Review coordinator resource against demand to provide quality service
Hestia
Northampton — recommendation 4.2.3.5
This recommendation is suggested in order to reduce the impact on those that have to manage the individuals and to prevent or reduce the automatic placement of personnel into departments that can take place without knowledge of wider implications.
Northamptonshire Police
Northamptonshire Police
Northampton — recommendation 4.2.3.4
Greater consideration should be given to the placement of officers/staff on restricted or ‘light duties’ taking account of their circumstances, the number allocated to a department and the additional stresses that can be caused to line managers.
Northamptonshire Police
Northamptonshire Police
Stoke-on-Trent — recommendation Derbyshire County Co
If allocated workers are absent for more than 3 weeks a case support plan including cover arrangements should be drawn up by managers.
Derbyshire County Council Children’s Services
Derbyshire County Council
Leicester — recommendation 6
It is recommended that caseloads of the multi-professional Community Mental Health Teams be assessed for acuity and limits set to ensure that the clinicians have the capacity to deliver the services to the required standards. This should be achieved within three months, and monitoring systems put in place to enable …
Leicestershire Partnership NHS Trust
Leicestershire Partnership NHS Trust
Cornwall — recommendation 21.11.5
The Devon and Cornwall Police Public Protection Unit’s Serious Case Review Team should consistently be fully staffed to ensure that incidents warranting a statutory review are correctly identified and referred to the specific authorities responsible for initiating statutory reviews.
Devon and Cornwall Police
Devon and Cornwall Police
Dudley — recommendation 8
Adult Social Care should provide evidence of how it has improved its response to MARAC and achieved outcomes for domestic abuse victims in the following areas: • Prioritisation of MARAC cases and workload capacity of staff enabling an urgent response • Co-terminosity between Multi-Agency Safeguarding Hub and MARAC • Effective …
Adult Social Care
Adult Social Services
Northampton — recommendation ASC4
NCC ASC Team to be reorganised in line with the move to a Unitary Authority in April 2021.
Northamptonshire County Council Adult Social Care …
South Worcestershire — recommendation 22
Formal guidance to be drafted to formalise the current allocation procedure considering level of skill/role of staff.
Adult Social Care, Worcestershire County Council
Dudley — recommendation DCCSEH_1
Family support staff absence. Cases to be monitored by line manager during staff absence. Cases are RAG rated in respect of known risks and contact is maintained with families through the use of the duty system operated within each Family Support Team. Consideration given to re-allocate cases if RAG rating …
Dudley Council Children’s Services - Early …
Dudley Council
Gloucester — recommendation 13
Gloucestershire MARAC review its current capacity against the expected volume of cases for the population it covers and look to increase capacity, particularly around decision-making. An additional MARAC decision-maker would increase capacity and resilience in the model.
Gloucestershire MARAC
St Helens — recommendation 15.6
In order to facilitate effective risk assessment organisations must acknowledge that staff representing them at MARAC meetings require sufficient time to adequately research cases and individuals before attending the MARAC and afford them that resource.
St Helens Peoples Board
West Berkshire — recommendation 7
The admission system should more fully support allocating of contacts to a team or group of individuals, versus contact with a new staff member for each service contact, to promote consistency in the response and to ensure that a trusting relationship may be developed.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Kent — recommendation 1
The Chief Constable should review this case and ensure Kent Police understand the issues behind why officers could not deploy to an ‘Immediate Response’ call in the required timeframes. The Chief Constable to provide the outcome of this review to the Police and Crime Commissioner and report on whether resourcing …
Kent Police
Kent Police
Nuneaton and Bedworth — recommendation 7
Warwickshire County Council, as the commissioner of domestic abuse services, completes a review of the IDVA service to ensure that resources are maximised and deployed effectively to adequately support high risk victims across the County. This should include exploring alternative, flexible models of multi- agency support. The findings of the …
Warwickshire County Council
Warwickshire County Council
Nottingham — recommendation Equation 1
Policies and procedures, staff induction/training/management is in place to ensure Referral timeframes are met. However, management can monitor Helpline capacity/waiting lists to ensure Equation has resources to meet this requirement.
Equation
Dudley — recommendation 8
Adult Social Care should provide evidence of how it has improved its response to MARAC and achieved outcomes for domestic abuse victims in the following areas: • Prioritisation of MARAC cases and workload capacity of staff enabling an urgent response • Co-terminosity between Multi-Agency Safeguarding Hub and MARAC • Effective …
Adult Social Care
Adult Social Services
Croydon — recommendation 6.1.10.y
ACTION 2: Victim Support should ensure that services are resilient to pressures from restructure and resource limitations, and that business continuity plans are in place that account for IT failures, staff turnover and vacancy/absence cover, and that contact is prioritised in relation to risk as well as contact Service Level …
Victim Support
Newcastle-Under-Lyme — recommendation d
Operational Communications Department managers review the failure rate of attendance at priority incidents to establish if this can be improved upon and also to ensure that the current gradings are appropriate given the outcome of this particular case.
Staffordshire Police
Staffordshire Police
Norfolk — recommendation 10
The National Probation Service has identified a number of service specific recommendations which this review recommends are undertaken: • To plan and implement effective measures to reduce caseloads and workload pressure on staff working at the relevant office • To widen and improve the recruitment campaign/package to encourage new applicants …
National Probation Service
National Probation Service
Manchester — recommendation 2
That Manchester Community Safety Partnership seek assurance from GMP that the policy of escalating incidents where the unavailability of resources would have the most detrimental effect is now fully embedded in practice.
Manchester Community Safety Partnership | Greater …
Greater Manchester Police
Sefton — recommendation 10
The Trust should ensure that newly qualified staff are afforded the correct level of caseload protection .
Merseyside Probation Trust
Probation Service
Dudley — recommendation BCHC_1
Assurance required within the health visiting service that process is applied when there are workforce absences.
Birmingham Community Healthcare NHS Trust
Birmingham Community Healthcare NHS …
Oxford — recommendation 6
Thames Valley Police to consider and implement options in relation to who should conduct research (secondary investigation) for Missing Person Investigations. An options paper should be completed addressing the viability of the following: Responsibility remaining with the attending officer Missing Person Co-ordinator Information Research Bureau
Thames Valley Police
Thames Valley Police
Chiltern — recommendation TVP Recommendation 1
Thames Valley Police to review its capacity to manage high risk domestic abuse victims. This should look at the recent increase in victims being assessed as high risk and the reasons behind this.
D/Supt – Crime and PVPSU (TVP) …
Kingston upon Thames — recommendation 26
All IDVAs should know they can ask other IDVAs or local Service Delivery Managers to provide a ‘holding service’ to their clients during periods of extended leave.
Victim Support
North Yorkshire — recommendation 11
The Community Safety Partnership should carry out a review of the MARAC operating procedures within North Yorkshire. Where practices are working well staff should be recognised. The frequency of MARAC meetings should be considered together with the administrative support available to support the Chair ensuring actions are completed in a …
North Yorkshire Community Safety Partnership | …
Durham — recommendation 10.2.5
Staffing-Licensing function to be part of constabulary’s operational core business, with long term investment of operationally capable staff.
Durham Constabulary
Durham Constabulary
Lambeth — recommendation 6.3
It is recommended that London Probation explores whether the role of the WSO could be developed to make them more involved in decision making in the management of orders with an IDAP requirement.
London Probation Trust
Probation Service
Kent — recommendation 6.6
The planned review by Kent Police of the police central referral unit (CRU) should consider the capacity of the unit to carry out effective assessments of crime and secondary incident reports of domestic abuse graded as ‘standard’ risk. The review should also consider whether the assessment of such cases should …
Kent Police
Kent Police
Central Bedfordshire — recommendation 9
Bedfordshire Police to audit the timeframes for referrals made at periods of peak demands and identify mitigating actions to ensure prompt onward referral to partner agencies.
Bedfordshire Police
Bedfordshire Police
Ealing — recommendation 7.5.2(b)
Development of lead roles on key areas by particular team members
Ealing Children’s Social Care
Ealing Council
Cornwall — recommendation 21.9.1
As the success of the MARAC and associated reduction in risk and increased positive outcomes for all impacted parties is entirely dependent on service engagement and prioritisation of the MARAC; Cornwall MARAC management & members have developed an improved MARAC process in Cornwall. To maximise its potential, all services and …
MARAC
East Sussex — recommendation 8.2.5
NPS to continue to apply national allocation process.
National Probation Service Sussex
National Probation Service
CJINI inspection reports(1)
CQC enforcement actions(12)
Warning Notice: Northern Care Alliance NHS Foundation Trust
Following the September inspection, CQC issued a warning notice to the trust to highlight the areas where rapid and significant improvements were needed. The service didn’t have effective systems and processes in place to ensure the wards had enough suitably …
Salford Royal Hospital
Oct 2025
Warning Notice: Tees, Esk and Wear Valleys NHS Foundation Trust
The Care Quality Commission (CQC) issued Tees, Esk and Wear Valleys NHS Foundation Trust with a warning notice following inspections from June to August. This action was taken due to concerns around unsafe staffing numbers and poor culture within forensic …
Dec 2021
Warning Notice: South East Coast Ambulance Service NHS Foundation Trust
The Care Quality Commission issued a Warning Notice to South East Coast Ambulance Service NHS Foundation Trust, requiring significant improvements in the quality of its services. This action followed a comprehensive inspection in May, which identified six main areas of …
Jul 2016
Warning Notice: University Hospitals Birmingham NHS Foundation Trust
Section 29A warning notice issued in February 2023 relating to insufficient medical staffing to provide safe care and treatment in triage, the pregnancy assessment emergency room, at Birmingham Heartlands Hospital. A subsequent inspection found improvements had been made and the …
Birmingham Heartlands Hospital
Feb 2023
Warning Notice: County Durham and Darlington NHS Foundation Trust
CQC identified significant and serious safety concerns during the surgery inspection. These related to safe staffing, escalation when people were deteriorating, record keeping and learning from incidents. Due to these issues, the trust has been told to make significant improvements …
Bishop Auckland Hospital, Darlington Memorial Hos…
Nov 2025
Warning Notice: Plymouth Hospitals NHS Trust
The Care Quality Commission issued a formal warning to Plymouth Hospitals NHS Trust, requiring urgent improvements to protect patients undergoing surgery at Derriford Hospital. This action followed an unannounced inspection where the trust did not meet five national standards, including …
Derriford Hospital
Jul 2013
Warning Notice: Buckinghamshire Healthcare NHS Trust
CQC issued a formal warning to Buckinghamshire Healthcare NHS Trust following an unannounced visit to Amersham Hospital on 4 July 2013. Inspectors found that the service was not taking appropriate steps to ensure sufficient numbers of suitably qualified staff were …
Sep 2013
Warning Notice: East Suffolk and North Essex NHS Foundation Trust
Inspectors served the trust a warning notice due to concerns about people’s safety and the management of these services. Staff weren’t able to triage everyone arriving at the emergency department within their goal of 15 minutes, and some people waited …
The Ipswich Hospital
Oct 2025
Warning Notice: Northern Devon Healthcare NHS Trust
The Care Quality Commission (CQC) inspected medical care services at North Devon District Hospital in July following concerns about staffing levels. Inspectors found a high number of vacancies and issues with medical staff availability and responsiveness for deteriorating patients, which …
North Devon District Hospital
Nov 2021
Warning Notice: Kent and Medway NHS and Social Care Partnership Trust
The Care Quality Commission issued a warning notice to Kent and Medway NHS and Social Care Partnership Trust, requiring significant improvements to its community-based mental health services for adults of working age. This followed an inspection where CQC found that …
May 2018
Warning Notice: Sandwell and West Birmingham Hospitals NHS Trust
Section 29A warning notice covering maternity services at City Hospital, Birmingham, following an inspection in June 2024 after which the safe rating declined from good to inadequate. The notice focused the trust's attention on making significant improvements around the environment, …
City Hospital, Birmingham
Nov 2024
Warning Notice: East of England Ambulance Service NHS Trust
Section 29A warning notice concerning the trust's Emergency Operations Centres: mandatory training not kept up to date, call waiting times below national standards, insufficient staffing and cultural concerns across the three sites.
Jan 2025