Informal user feedback
Informal and insufficient processes for providing feedback to service users, leading to a lack of clarity and accountability.
Source spread
Where this theme appears
This theme appears across 15 independent accountability sources, so the source mix matters as much as the headline total.
17 inquiry recs
11 PFD reports
49 committee recs
1 HSSIB rec
88 CQC actions
4 NAO recs
33 IMB recs
1 Scottish FAI
2 detention investigation recs
7 DHR recs
70 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(17)
27 — Workforce involvement in safety
Recommendation: The regulatory body, operators and contractors should support and encourage the involvement of the offshore workforce in safety. In particular, first line supervisors should involve their workforce teams in everyday safety (para 18.48).
Unknown
22 — Consultation on guidance notes
Recommendation: In connection with the preparation of guidance notes the regulatory body should review the procedures for consultation so as to ensure that the views of the representatives of employers and employees involved in work offshore are adequately taken into account …
Unknown
IHRD-64 — Parental Involvement in Training
Recommendation: Parents should be involved in the preparation and provision of any such training programme.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-63 — Evaluation of Parental Involvement
Recommendation: The practice of involving parents in care and the experience of parents and families should be routinely evaluated and the information used to inform training and improvement.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F256 — Follow up of patients
Recommendation: A proactive system for following up patients shortly after discharge would not only be good "customer service", it would probably provide a wider range of responses and feedback on their care.
Gov response: Accepted. A good trust will take every opportunity to seek patient feedback. A good complaints system will recognise that some people will give fuller feedback once they have had time to reflect and therefore it …
Accepted
F255 — Using patient feedback
Recommendation: Results and analysis of patient feedback including qualitative information need to be made available to all stakeholders in as near "real time" as possible, even if later adjustments have to be made.
Gov response: Accepted. Many local Trusts are devising innovative ways to take this forward. Feedback from patients, carers and the public can be made on the quality of care through a range of technologies and channels including …
Accepted
F254 — Access for public and patient comments
Recommendation: While there are likely to be many different gateways offered through which patient and public comments can be made, to avoid confusion, it would be helpful for there to be consistency across the country in methods of access, and for …
Gov response: Accepted. Feedback from patients, carers and the public can be made on the quality of care through a range of technologies and channels including online, via bedside televisions, surveys and the friends and family test. …
Accepted
BRIS-166 — PCTs must involve public in commissioning hospital services and gather feedback
Recommendation: Primary care trusts (and groups), given their capacity to influence the quality of care in hospitals, must involve patients and the public, for example through each PCG/T’s Patient and Advocacy Liaison Service. They must make efforts systematically to gather views …
Unknown
BRIS-165 — NHS Modernisation Agency to advise on achieving widest public and patient involvement
Recommendation: The involvement of the public, particularly of patients, should not be limited to the representatives of patients’ groups, or to those representing the interests of patients with a particular illness or condition: the NHS Modernisation Agency should advise the NHS …
Unknown
BRIS-164 — Provide financial resources to support public involvement, covering costs like childcare
Recommendation: Financial resources must be made available to enable members of the public to become involved in NHS organisations: this should include provision for payments to cover, for example, the costs of childcare, or loss of earnings.
Unknown
BRIS-163 — Provide training and guidance to properly support public involvement processes
Recommendation: The process of public involvement must be properly supported, through for example, the provision of training and guidance.
Unknown
R58 — Lay representation on IPC committee
Recommendation: Health Boards should ensure that there is lay representation at Board infection prevention and control committee level in keeping with local policy on public involvement.
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
F289 — Experience on the front line
Recommendation: Department of Health officials need to connect more to the NHS by visits, and most importantly by personal contact with those who have suffered poor experiences. The Department of Health could also be assisted in its work by involving patient/service …
Gov response: Accepted. A major programme has been established within the Department of Health to ensure that staff throughout the organisation are given the opportunity to experience the realities of life in front-line organisations. The programme has …
Accepted
F233 — For joint action Profile
Recommendation: While both the General Medical Council and the Nursing and Midwifery Council have highly informative internet sites, both need to ensure that patients and other service users are made aware at the point of service provision of their existence, their …
Gov response: Accepted. Both the General Medical Council and the Nursing and Midwifery Council have made clear their commitment to ensure that patients and the public have a clear understanding of the role of both organisations. The …
Accepted
F230 — Profile
Recommendation: The profile of the Nursing and Midwifery Council needs to be raised with the public, who are the prime and most valuable source of information about the conduct of nurses. All patients should be informed, by those providing treatment or …
Gov response: Accepted. The Nursing and Midwifery Council is working to develop its public profile, and will be re- launching its website and developing information for patients, the public and employers. It has embarked on a programme …
Accepted
LADB-60 — Conduct market research on safety measures to include informed passenger views
Recommendation: Comprehensive market research in regard to safety related measures should be carried out in order to take account of the views of informed passengers (para 13.20).
Unknown
IHRD-89 — Patient Concern Organisation
Recommendation: The Department should consider establishing an organisation to identify matters of patient concern and to communicate patient perspective directly to the Department.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
Prevention of Future Deaths reports(11)
Joshua Brown
Concerns: The coroner noted limited information sharing with Mr. Brown's parents, his primary support, due to his wishes and their non-carer status, which impacted their ability to assist the team. There was also no system for family members to review and confirm the accuracy of notes made by the community team.
Response (Department of Health): • The Department of Health facilitated and published a consensus statement on confidentiality, information sharing, and suicide prevention in January 2014. • The consensus statement advises practitioners to discuss information … (AI summary)
Overdue
Lorraine Youngs
Concerns: The coroner noted delays in implementing an agreed care package and identified that there appeared to be no system for following up the implementation of such packages, raising concerns about potential impacts on vulnerable service users.
Response (Lorraine Youngs): • Norfolk County Council established a dedicated Hospital Discharge Social Care team in May 2015. • The new team ensures timely assessments, discharge planning, and follow-up of agreed actions, with … (AI summary)
Responded
Dorota Kijowska
Concerns: The outcome of a review meeting was not signed off in writing by those in attendance and was not clearly communicated to the individual concerned.
Overdue
Dennis Oldland
Concerns: Concerns were raised that care workers leaving visits early could lead to insufficient interaction with service users, potentially overlooking risks to their welfare.
Overdue
Simon Barber
Concerns: The coroner noted inadequate risk assessments by First Class Care and identified a need for staff to be aware of the importance of reporting all incidents that endanger service user safety.
Response (Nottingham City Council): • Nottingham City Council’s Occupational Therapy Service’s Ramping policy was reviewed to address risks associated with single ramped access points and fire safety. • Nottingham City Homes and Nottingham City … (AI summary)
Responded
Geraint Hughes
Concerns: The coroner identified a lack of formal carer's assessments and irregular contact from the case coordinator, leading to outdated care plans and risk assessments. Concerns were also raised about supervisory arrangements failing to detect these issues.
Response (Cornwall Partnership NHS Trust): • The Trust has introduced the Triangle of Care standards across its mental health services, appointed Carers Leads, and delivered staff awareness sessions. • The Trust's Carers Policy is currently … (AI summary)
Responded
Ailsa Stewart
Concerns: The coroner noted a lack of cohesive national guidance across health and social care regarding the suspension of domiciliary care packages. Concerns were also raised about the absence of specific rules for agencies to convey information when vulnerable patients are discharged from urgent care settings without formal admission.
Response (Department of Health Social Care): • The Government published guidance for home care providers covering hospital discharge. • Stockport NHS Trust shared a safety alert to practitioners regarding patient vulnerability and discharge. • North West … (AI summary)
Responded
Beryl Simcock
Concerns: The coroner noted a lack of written policies for care planning and risk assessments, with concerns that reviews were either not completed or records were falsified. Additionally, family members were not always given timely information about significant incidents or deprivation of liberty.
Response (Radcliffe Manor House): • The care home commissioned a consultancy company to review its governance processes. • The trustees are procuring a digital care planning system and a total quality system, aiming for … (AI summary)
Response (Swift Management services): • The home implemented new falls management policies and procedures. • Management oversight of care plan documentation was improved, with enhanced linking between care plans, risk assessments, and incident reports. … (AI summary)
Responded
Thomas Godderidge
Concerns: The coroner noted a lack of reliable liaison between Adult Social Care and care providers when capacity concerns are raised, leading to missed opportunities. There were also concerns that capacity assessments do not consistently account for variable and fluctuating capacity.
Response (Cumberland Council): • Cumberland Council is developing a guidance and briefing note for care providers on how to raise concerns regarding potential changes in a person’s mental capacity. • The council has … (AI summary)
Responded
Owen Gardner
Concerns: The coroner noted that individuals with cognitive deficits may miss important appointments if their next of kin are not consistently informed of short-notice changes, as there is no system to facilitate this communication.
Response (Norfolk and Suffolk NHS): • The Trust is procuring a new Electronic Patient Record system and has commenced work on enhancing its current system to facilitate communication with next of kin. • A patient … (AI summary)
Responded
Janet Brown Townend
Concerns: Carers provided insufficient visit times and did not escalate Ms Townend's deteriorating health or inaccurate Early Warning Sign records. Concerns were also raised about the lack of follow-up on her seeking GP support or reassessment of capacity for unwise decisions.
Response (CQC): • The CQC reviewed its records, contacted the service regarding a missing statutory notification, and requested the deceased's care records. • The CQC received action plans from the provider addressing … (AI summary)
Response (East Riding of Yorkshire Council): • The Council addressed practice issues identified in the enquiry with the individual practitioner and disseminated lessons learned within the team. • The adult safeguarding service implemented a new service … (AI summary)
Overdue
Select committee recommendations(49)
#65 —
Recommendation: It is positive that OfS senior staff now intend to visit higher education providers more regularly, as this kind of informal contact between institutions can provide valuable insights that cannot be gleaned from datasets.
Response attribution not verified
#53 —
Recommendation: The difference in resources between individual consumers and businesses has the potential to distort the feedback and representations that regulators receive. In some areas, this potential gap is at least partially remedied by statutory provision for independent consumer advocacy, as …
Response attribution not verified
#52 —
Recommendation: Where they do not do so already and where resources allow, regulators should survey those they regulate, ideally annually. Summaries of the results of these surveys should be made public.
Response attribution not verified
#32 —
Recommendation: Beyond the General Review, the Government should keep us and other stakeholders informed of developments in the various chapters of CPTPP. We also recommend that a programme of stakeholder engagement should continue, building on that currently underway for the General …
Response attribution not verified
#86 —
Recommendation: Anyone looking to reform high streets should involve the local authority at an early stage and develop a shared vision. Where a local authority is seeking to lead change it must work in partnership with landlords, business owners and the …
Response attribution not verified
#83 —
Recommendation: Reflecting on the Heritage Action Zone programme, Historic England noted its success in working with local trusts who were better able to understand local needs and had fewer restrictions to how they work, compared with local authorities. 160 Mark Robinson, …
Response attribution not verified
#72 —
Recommendation: High streets are at their most vibrant when they are used by the whole community. Local authorities should ensure that their residents are involved in decision-making about their area through both formal consultations and partnership working.
Response attribution not verified
#71 —
Recommendation: Former Government programmes, such as the New Deal for Communities, incorporated this approach by establishing a number of local partnerships to oversee local regeneration projects. 145 The Long-Term Plan for Towns, established by the previous Government, also sought to actively …
Response attribution not verified
#70 —
Recommendation: Ministers from the new Government emphasised to us that they believe local communities are central to any future work to improve high streets and town centres. The Lords Minister for Housing and Local Government, Parliamentary Under-Secretary Baroness Taylor of Stevenage, …
Response attribution not verified
#69 —
Recommendation: Reflecting on the potential of Community Improvement Districts , but that acknowledging the framework for these remains unclear, the Government should explore whether the Business Improvement District model should be expanded to require the participation of community representatives beyond local …
Response attribution not verified
#67 —
Recommendation: In reviewing its work with 67 high streets across the country to deliver the Heritage Action Zones programme, Historic England identified that local governance structures that gave local communities a say in decisions were key in ensuring that places met …
Response attribution not verified
#66 —
Recommendation: Whilst some centres may thrive because of seasonal tourist trade, we heard that high streets primarily exist to serve their local communities. 132 Professor Tomaney suggested that the future of successful high streets and town centres “lies in creating a …
Response attribution not verified
#14 —
Recommendation: High streets are at their most vibrant when they are used by the whole community. Local authorities should ensure that their residents are involved in decision-making about their area through both formal consultations and partnership working.
Response attribution not verified
#9 —
Recommendation: Thriving businesses are essential for a busy and successful local high street and business owners should be actively involved in the management of their high street.
Response attribution not verified
#9 —
Recommendation: The Government should improve existing mechanisms for stakeholder engagement. Within six months, the MOJ should create a stakeholder forum which provides opportunities for regular and direct feedback from frontline legal professionals working with interpreters in the courts, and interpreters delivering …
Response attribution not verified
#8 —
Recommendation: Despite the Government’s efforts, frontline staff do not feel engaged with or represented in discussions with the Government regarding interpreting in the courts.
Response attribution not verified
#29 —
Recommendation: We asked the Departments what feedback they had received from victims about transparency during the claim process and what it was doing to address feedback it received. DBT told us it amended the claim guidance on the Horizon Compensation Schemes, …
#1 —
Recommendation: It is crucial that any process of reform to mental health law hears from individuals with direct, personal experience. We welcome the Bill’s proposal to introduce a requirement to offer de–briefing to mental health patients after they have left hospital, …
Response attribution not verified
#30 —
Recommendation: Forming a ‘Creators Council’ could boost confidence across the sector and ensure its views are represented at a time when many of the creative industries workforce are struggling to stay in the sector. We recommend that DCMS forms a Creators …
Response attribution not verified
#5 — Develop and publish a comprehensive stakeholder engagement framework for marine decision-making by January 2025.
Recommendation: We recommend that the Department for Environment, Food and Rural Affairs (DEFRA) develops a comprehensive framework for engaging a diverse range of stakeholders, particularly coastal communities and underrepresented voices, early-on in marine decision-making and outline the responsible organisation for leading …
Response attribution not verified
#4 — Strengthen stakeholder engagement across all marine policy areas within Defra.
Recommendation: Engaging stakeholders in a meaningful way is essential to ensure that decisions are inclusive, transparent, and responsive to both environmental and societal needs. For engagement to be effective, it must occur through appropriate forums, begin early in the decision-making process, …
Response attribution not verified
#4 — Ensure care-experienced young people's full engagement and involvement in social care accountability mechanisms.
Recommendation: The Department should ensure that it is engaging with care-experienced young people in all areas of its work on children’s social care and should encourage local authorities to do the same. The Department for Education, 82 Ofsted and the Care …
Response attribution not verified
#58 —
Recommendation: The content of the Support with Employee Health and Disability website should reflect the barriers and challenges faced by both employers and disabled people and should be developed in partnership with disabled people, disabled people’s organisations and employers. The site …
Response attribution not verified
#3 —
Recommendation: We also received written submissions from a range of different sources including voluntary sector organisations, academic and researchers as well as wider government stakeholders. A list of the written evidence is available on the inquiry page of the Committee’s website.3 …
#58 —
Recommendation: The Office for Investment together with the new Business Growth Service should: a. ensure there is a single front door for accessing the full range of their services; b. conduct an annual survey of business to evaluate the products offered …
Response status not verified
#3 —
Recommendation: The Government should take a more proactive and leading role in communicating a positive vision of the EV transition to consumers, and promoting comprehensive, clear, authoritative, accurate and balanced information. The Government should develop a communication strategy in collaboration with …
Response attribution not verified
#28 —
Recommendation: Working with the Office for Students, the Government should review the provision and quality of accessibility information provided by universities to students. This should include physical accessibility of spaces, adjustments available to students and previous examples of how adjustments have …
Response attribution not verified
#168 —
Recommendation: It was also noted that bids could be more effective and successful if they were developed, at least in part, by individuals operating outside local government who may have a better understanding of the needs of the community. Morecambe Town …
Response attribution not verified
#15 —
Recommendation: We are pleased to hear that Ministers are seeking to learn from previous successful programmes. The Government should ensure that accountability mechanisms involving members of the local community, such as Towns Boards , are part of any new programmes to …
Response attribution not verified
#15 —
Recommendation: The National Audit Office (NAO) found that, although each regulator sets rules and expectations regarding how companies communicate with customers, many customers still find it difficult to contact the company supplying them. For example, in 2024 only 64% of broadband …
#13 —
Recommendation: In bringing forward the “duty to collaborate” the government should set out a clear ambition to tackle the poorer outcomes including increased risks of homelessness that minority ethnic groups experience in leaving the care of public services. The government should …
Response status not verified
#13 —
Recommendation: The Cabinet Office has given clusters discretion over their delivery models. This has led to several different approaches to clusters’ implementation of shared services.31 Written evidence we received from the Public and Commercial Services Union (PCS) noted that civil servants …
Response status not verified
#56 —
Recommendation: We support the creation of a Survivor Advisory Council. Such a body could empower survivors of forced labour to contribute to meaningful legislative change and policy reform. (Conclusion, Paragraph 279)
Response attribution not verified
#24 —
Recommendation: While we welcome the communication of Covid-19 guidance by providers to their service users, we urge all providers to check regularly with their service users, and with wider stakeholders, to ensure that they are receiving up to date and timely …
Response attribution not verified
#3 — Streamlined, transparent marine governance and stakeholder engagement are crucial for protection commitments.
Recommendation: A more streamlined and transparent approach to marine governance, underpinned by effective stakeholder engagement, is essential for the Government to meet its marine protection commitments and to ensure a balanced approach to managing the economic, social, and environmental demands placed …
Response attribution not verified
#52 — Introduce opt-out independent advocacy for all children in care, including disabled children.
Recommendation: The Department for Education must take forward the recommendation of the Independent Review of Children’s Social Care to introduce an opt-out model of independent advocacy for all children in care. It must also act 90 on the Child Safeguarding Practice …
Response attribution not verified
#51 — Too few children, especially disabled, access entitled independent advocacy support in care.
Recommendation: It is essential that children in care have a voice when important decisions are being made about their lives. Currently, too few children are accessing the advocacy support they are entitled to, with an average referral rate of just 5% …
Response attribution not verified
#3 — Care-experienced young people's voices vital and require broader inclusion across government levels.
Recommendation: We were privileged to hear powerful and insightful evidence from care-experienced young people in this inquiry, and their voices have informed many of the conclusions and recommendations in this report. We are pleased that the Department is regularly hearing from …
Response attribution not verified
#23 — Engage parents of SEND children during area inspections on local inclusive practices
Recommendation: Area SEND inspections should engage with parents across the locality to gather the perspective of parents of children with SEND on the admissions policies and inclusive practices of local authorities, schools and multi- academy trusts in the area. (Recommendation, Paragraph …
Response attribution not verified
#16 — Meaningful parental involvement is crucial for successful SEND system outcomes and trust
Recommendation: Parents and carers of children and young people with SEND often feel excluded from the processes that affect their children’s education and support. However, meaningful and collaborative parental involvement is essential to the success of the SEND system. When parents …
Response attribution not verified
#160 —
Recommendation: Throughout their evidence session with us, the new Ministers emphasised the central role of local authorities and local communities in deciding the spending priorities for their area and managing their spending in line with this. 323 When questioned about how …
Response attribution not verified
#28 —
Recommendation: HS2 Ltd told us that the nature of the High Speed 2 programme means that the work required for it will be disruptive. HS2 Ltd estimated it had handled 124,000 queries over the past three years and interacted with over …
Response attribution not verified
#19 —
Recommendation: We believe the Electoral Commission should be sensitive to the role of volunteers in campaigns and the potential for inadvertent reporting errors to occur. We welcome the Electoral Commission’s proposed changes to the Political Finance Online platform to support individuals …
Response attribution not verified
#13 —
Recommendation: We received written evidence from stakeholders representing asylum seekers who told us that they needed information on the contracts’ performance to help them better support people. The Refugee Council told us that they needed greater transparency over service standards and …
Response attribution not verified
#5 — Require IREF to set higher fan engagement licensing conditions independently of existing standards.
Recommendation: IREF, beginning in shadow form, should ensure that its licencing conditions regarding fan engagement are set independently of the current Premier League Fan Engagement Standard. Unless there is immediate and significant change from leagues and clubs, we expect that IREF …
Response attribution not verified
#4 — IREF presents a significant opportunity to accelerate and strengthen fan engagement in football.
Recommendation: The introduction of IREF remains a great opportunity to increase the pace of the important work that is already underway at football clubs consulting and engaging with their fans. Whilst clubs should be encouraged to exceed fan engagement standards and …
Response attribution not verified
#3 — Premier League fan engagement standards are inadequate for consistent high-quality club interaction.
Recommendation: We welcome the Premier League’s fan engagement standard and commend the Premier League for acting prior to the publication of the White Paper. However, the level of fan engagement from Premier League and EFL clubs still varies wildly and we …
Response attribution not verified
#9 — Require energy companies to use contact empathy as a measure of customer service success.
Recommendation: We recommend that contact empathy be used as a measure of success in customer service provision by energy companies. This would help to rebuild trust in the sector.
Response attribution not verified
#23 — Update tenant satisfaction measures to include shared owners' satisfaction with repairs and maintenance.
Recommendation: We welcome the Government’s confirmation that the Regulator is preparing to introduce a new, proactive consumer regulation regime. However, for the next round of tenant satisfaction data collection, the Regulator must update the measures to include satisfaction with repairs and …
Response attribution not verified
HSSIB safety recommendations(1)
NCEPOD recommendations(1)
CQC inspection actions(88)— showing 50 strongest matches
University Hospital of Hartlepool
The service should put plans in place to increase response rates to the NHS Friends and Family Test in the Children’s Day Unit.
Should Do
The County Hospital
The service should consider improving the response when requesting patient feedback.
Should Do
Royal Victoria Infirmary
The service should further improve the quality of food provided to all patients and seek regular patient feedback.
Should Do
Royal Victoria Infirmary
The service should further improve the quality of food provided to all patients and seek regular patient feedback.
Should Do
Royal Shrewsbury Hospital
The service should ensure all patients are able to discuss any concerns with staff.
Should Do
Princess Royal Hospital
The hospital should consider improving engagement with patients and their families to increase the response rate of the friends and family test surveys.
Should Do
Kidderminster Hospital and Treatment Centre
The trust should ensure that it has processes and procedures in place to increase the response rate for the Friends and Family Test response within the medicines service.
Should Do
Kidderminster Hospital and Treatment Centre
The trust should ensure that the medicine service reviews the response rate for the friends and family test.
Should Do
Kidderminster Hospital and Treatment Centre
The serviceshould review methods of gaining patient feedback and improve their response rates.
Should Do
Kidderminster Hospital and Treatment Centre
Improve the Friends and Family Test response rate on Riverbank ward and the children’s outpatient department.
Should Do
Kidderminster Hospital and Treatment Centre
The trust should ensure that it has processes and procedures in place to increase the response rate for the Friends and Family Test response within the medicines service.
Should Do
Glemsford Surgery
Continue to engage in patient feedback/survey exercises to gain and act upon patient opinion to improve patient satisfaction.
Should Do
Clatterbridge Hospital
The services should find ways to include the patient voice, community groups, and relevant stakeholders in developing its strategy and services.
Should Do
Clatterbridge Hospital
The trust should consider ways in which engagement with the wider public is improved.
Should Do
Airedale General Hospital
The service should continue to engage in the development of the maternity voices partnership and develop systems to gain insight and feedback from people who use the maternity service.
Should Do
Withington Community Hospital
The trust should consistently obtain NHS Family and Friends data in the radiology department.
Should Do
Windsor Dialysis Unit
Continuetoengagewithstafftogetfeedbackontheserviceanditsmanagement.
Should Do
Trust Head Office, CEME
Implement a system with the provider who manages the SARC to ensure feedback from patients, families and carers, is obtained to provide an opportunity for improvements to be made to the service when needed.
Should Do
The Sidings Medical Practice
Develop a system to gather patient feedback that is also accessible to people whose first language is not English.
Should Do
The Sidings Medical Practice
Continue their work to improve patient satisfaction in the areas identified in the GP Patient Survey.
Should Do
Sunderland Eye Infirmary
Introduce patient surveys specific to the outpatient department.
Should Do
Moorcroft Medical Centre
Maintain oversight and continue to monitor and review patient feedback on access.
Should Do
Market Weighton
Continue to monitor access to the practice, audit and analyse the new appointments system and continue to monitor patient feedback.
Should Do
Durham Diagnostics and Treatment Centre
The service should improve its engagement with patients, staff, equality groups, the public and local organisations to plan and manage services.
Should Do
Durham Diagnostics and Treatment Centre
The service should continue to engage with staff and patients to inform service developments.
Should Do
Alder Hey Children's Hospital
Provide visible and accessible information to patients to help them to feedback and/or make complaints about the service.
Should Do
Clova House Residential Care Home
The provider said they would record conversations with people about their views of the service and their care in future, and the manager also said they would record the discussions about care plans with people in future to ensure they …
Must Do
Prospects for People with Learning Disabilities - 3 Norwich Road
It is good practice to seek regular feedback from people who use the service and any other people involved in the service, such as, relatives, friends and professionals. This gives the provider information about what the service does well and …
Should Do
Holly House Residential Care Home
The provider should ensure the complaints system is effective and that people feel comfortable complaining and that their concerns are listened to and dealt with.
Should Do
St Austell Hospital - Penrice Birthing Unit
The service should consider improving how information is displayed on how to give feedback and make a complaint about the service.
Should Do
Ellesmere Port Hospital
The trust should implement effective patient engagement in the development of the trust’s services.
Should Do
St Benedict's Hospice
The service should improve its engagement with patients, staff, equality groups, the public and local organisations to plan and manage services.
Should Do
St Benedict's Hospice
The service should continue to engage with staff and patients to inform service developments.
Should Do
Royal Sussex County Hospital
The trust should engage with patients in such a way as to develop their services.
Should Do
Valewood House Nursing Home
We recommend that that manager considers a structured approach to gathering people’s views to ensure that they have regular opportunities to share concernsor ideas.
Should Do
Benthorn Lodge
The registered person had failed to ensure suitable systems were in place so that people could be supported to voice their opinions or raise concerns about their care and treatment.
Must Do
St Albans House
The provider must ensure that the systems in place to quality assure and check the care being provided are effective. The provider must actively seek the views of people living at the service to ensure the continuous improvement of the …
Must Do
Ranyard at Mulberry House
Systems were not established to seek and act on feedback from relevant persons on the services provided for the purposes of continually evaluating and improving the services.
Must Do
Ranyard at Dowe House
We recommend that the service find ways to consult and gather the feedback of people about the service provided.
Should Do
Pheonix Healthcare
The registered person must effectively act on feedback from relevant persons and other persons on the services provided, for the purposes of continually evaluating and improving the services.
Must Do
Oak Tree Manor
However, we noted that the notes for these meetings did not include a record of discussion or staff voice. This was an area that needed to be developed to ensure all feedback and ideas were captured.
Should Do
Holly Court Care Home
We noted the complaints process was laminated and taped to the wall in a corridor on one of the units. We discussed the effectiveness and appropriateness of this with the deputy manager, who assured us it would be removed.
Should Do
Darenth Grange Residential Home
The provider should gather feedback and suggestions from relatives about the development of the service, including through questionnaires and exploring social media channels.
Should Do
Darenth Grange Residential Home
The provider should fully support people to contribute to the development of the service, ensuring regular residents' meetings are held and consultations with individuals are well-developed, recorded, and effective.
Should Do
Caremax Support Services Ltd
We recommend the provider consider their approach to supporting people to give feedback about the service and take action to improve their practice accordingly.
Should Do
Valewood House Nursing Home
The manager should consider a structured approach to gathering people’s views to ensure that they have regular opportunities to share concerns or ideas.
Should Do
Rosecroft Residential Care Home
The provider should ensure that action plans or records are in place to show how people's feedback from resident meetings and other sources has been consistently addressed.
Should Do
Chatting Independently Limited - Orchard View
The provider must ensure people who use the service could be assured that any complaints would be acted on investigated and resolved to their satisfaction.
Must Do
Ashmore House
The provider must establish and operate effective systems to seek and act on feedback from relevant persons to continually improve the service.
Must Do
The York Hospital
The trust must seek and act on feedback from relevant persons on the services provided, for the purposes of continually evaluating and improving such services.
Must Do
NAO audit recommendations(4)
Regulating the financial sustainability of higher education providers in England
e) set out how it will secure provider and stakeholder views of its work;
Accepted
Department for Work and Pensions Annual Report and Accounts 2020-21
Ensure that behavioural insights are used extensively in the design of controls to drive claimants towards more compliant behaviours. The Department should seek to understand how claimants respond to the interactions that they have with the Department and tweak controls …
Accepted
Department for Work and Pensions Annual Report and Accounts 2020-21
• improve the way it uses information from quality checks and explore how it can better use claimant and pensioner contact to identify systemic issues affecting payment accuracy.
Accepted
DWP Report on Account 2022/23
i DWP should collect information to provide assurance over the quality of customer service and report on this in its 2023-24 Annual Report and Accounts.
Partially accepted
IMB individual recommendations(33)
Heathrow Immigration Removal Centre (2020)
As soon as practically possible the Detainee Consultative Committee meeting should be resumed at scale to take account of the concerns of all detainees on both sites. These meetings are helpful in ensuring that detainees’ views are heard and their needs are met.
Governor / Director
Erlestoke (2025)
What urgent action will be taken to establish the new format of the prison council, so that prisoners can have an appropriate outlet for their concerns?
Governor / Director
Bedford (2020)
Request that the healthcare team provides the Board and prison managers with monthly data regarding patient satisfaction for both the healthcare team and the mental health team.
Governor / Director
Gatwick IRC/RSTHF (2022)
Establish a robust, repeatable mechanism for collecting and analysing views of the detained men about their perception of safety in the Gatwick centres (sections 4, 4.3).
Home Office
Wayland (2023)
Prison management should seek to discover why there has been this significant reduction [in the perceived utility of Prisoner Forums].
Governor / Director
Wayland (2023)
Perhaps, considering how much digital communication is now relied upon, prison management should seek to discover why there has been this significant reduction [in perceived utility of Prisoner Forums].
Governor / Director
Gatwick IRC (2021)
Home Office and Serco should consider how the perceptions of the detained men about their safety can be collected consistently through the year and used as a meaningful tool for improving the centres' management (section 4.3).
Home Office
Norwich (2022)
The Board asks the Governor to provide information on plans for ensuring that Prisoner representatives have time allocated in order to support their fellow prisoners.
Governor / Director
Norwich (2022)
The Board asks the Governor to provide information on plans for ensuring that scheduled forums take place and minutes are readily available for prisoners to see.
Governor / Director
Lindholme (2022)
We would urge that this initiative is reinforced in order to further reduce the dissatisfaction that arises amongst prisoners.
Governor / Director
Gatwick IRC/RSTHF (2022)
Establish a robust, repeatable mechanism for collecting and analysing views of the detained men about their perception of safety in the Gatwick centres (sections 4, 4.3).
Governor / Director
Feltham (2022)
What can the Prison Service do to raise the profile of the IMB within the new online resources available to prisoners via their prison-issued laptops? Could individual Boards have support to construct their own page specific to its particular presence in an establishment? Additionally, there is no online encouragement for prisoners to speak directly to IMB members about their experience …
HMPPS
Littlehey (2023)
The Board has been pleased to see the re-introduction of prisoner forums during this reporting year and the willingness of the prison to engage with the prisoner population to improve their lived experience. The Board has also heard the frustrations of prisoners who feel that these forums can be talking shops rather than action orientated. The Board would like to …
Governor / Director
Bronzefield (2023)
What plans are in place to re-introduce User Voice or a similar provision?
Governor / Director
Wayland (2024)
strongly recommend to all areas of the prison’s management, that further consultative investigation is done with prisoners to unpack the reasons behind this result, and, if justified, consider strategies to respond to the findings revealed.
Governor / Director
Durham (2020)
How can focus groups be introduced and sustained?
Governor / Director
Bedford (2020)
Build on the work already undertaken to create a more collaborative culture (for example, joint monitoring and planning meetings) aimed at giving prisoners a real role in helping to monitor and improve the prison regime.
Governor / Director
In Progress
Bedford (2020)
Develop methods for evaluating the key worker scheme.
Governor / Director
Parc (2021)
It was identified that a proportion of prisoners were positive about the Purple Visits service, and it is hoped that this will continue to be fully funded, with improved software to avoid random disconnections in the service.
HMPPS
In Progress
Thorn Cross (2024)
To make the Prison council a more effective means of consultation and communication.
Governor / Director
Dartmoor (2020)
The Board understands that it is now planned to bring facilitators to every wing under the Dialogue Road Mapping (DRM) scheme. However, the nature of DRM means that not much is heard about it, except by word of mouth. Can ways be found of raising its profile in the prison?
Governor / Director
Bedford (2020)
Consider if it might be useful to investigate how the current incentives and earned privileges (IEP) scheme could be modified to be more effective in incentivising prisoners.
Governor / Director
Bedford (2020)
Consider an evaluation of the ACCT process which takes into account the feelings of the prisoners involved regarding their safety and wellbeing.
Governor / Director
Implemented
Coldingley (2021)
The Board also hopes that the option of video calls will be maintained once social visits return to full capacity as many relatives, particularly those with young children, find it difficult to access the prison.
Governor / Director
North and Midlands Short Term Holding Facilities (2022)
Continue the constructive engagement with the Board and continue to attend the monthly meetings.
Other
North and Midlands Short Term Holding Facilities (2022)
Continue the constructive engagement with the Board and continue to attend the monthly meetings.
Home Office
Maidstone (2022)
Restart governor wing surgeries as soon as possible.
Governor / Director
Maidstone (2022)
Continue to seek ways to enhance the role of the community council.
Governor / Director
Ashfield (2022)
Can the Director share the survey’s findings, as well as the official prison statistics, with prisoners for transparency?
Governor / Director
Thorn Cross (2025)
Are the current arrangements for prisoner consultation through consultative committees and the Queensland meeting as effective as they could be? (5.3.2)
Governor / Director
Styal (2025)
How does the prison intend to improve opportunities for prisoner voice to be regularly heard and acted upon?
Governor / Director
Bronzefield (2025)
How does the prison plan to address the concerns raised by reception peer workers, as outlined in the fourth paragraph of section 4.1?
Governor / Director
Ashfield (2022)
Can the Director consider the resumption of the prisoner advice and liaison service (PALS)?
Governor / Director
Health investigations(38)
Independent investigation: Sidney Waller, Manchester (2008) — Rec 6
The PCT must be provided with assurances in relation to carer assessments and carer involvement and this will involve random audits in relation to carer assessments and family involvement, including user involvement in care planning and treatment.
north_west
Independent investigation: Angela Titley, Private Psych hospital, Redhill, Surrey (2004) — Rec R30
We recommend to the HC that it makes representations to the Department of Health, urging it to take such steps as may be necessary to enable the Mental Health Patient Survey to be extended to the independent sector.
south_east
Independent investigation: Robert CrookElsie Crook, Swindon (2007) — Rec Four
On the publication of this report a Lincoln-based service user and carer satisfaction survey should be conducted to ascertain the perceived effectiveness of the Integrated Care Pathway Approach. This survey to establish whether: good quality, relevant information was provided in a timely manner; the wishes and preferences of service users …
south_west
Independent investigation: Florise Corette, Lewisham (2015) — Rec 1.63
In terms of the impact of this action, the Trust should consider the available assurance to assist in this area, which may be through compliments, complaints or the National Inpatient Survey.
london
Independent investigation: Florise Corette, Lewisham (2015) — Rec 1.61
In terms of the impact of this action, the Trust should consider the available assurance to assist in this area, which may be through compliments, complaints or the National Inpatient Survey.
london
NHS England investigation into an unofficial call-handling project at South … — Rec 3
Patients and their carers should be present, powerful and involved at all levels of the organisation, including consultation on any projects that are implemented. Their voices should be seen as an asset in monitoring the safety and quality of care.
south_east
NHS England investigation into an unofficial call-handling project at South … — Rec 12
Organised engagement with patients and the public for timely stakeholder involvement needs to be formalised and actioned.
south_east
NHS England follow-up report into an unofficial call-handling project at … — Rec 2
Patients and carers should be present, powerful and involved at all levels of the organisation including consultation on any projects that are implemented. Their voices should be seen as an asset in monitoring the safety and quality of care
south_east
NHS England follow-up report into an unofficial call-handling project at … — Rec 11
Organised engagement with patients and the public for timely stakeholder involvement needs to be formalised and actioned
south_east
Independent investigation into the care and treatment of Christopher Stone-Houghton … — Rec 5
The Trust should ensure that carers are always offered an assessment of their caring needs which enables them to give feedback privately and facilitates thoughtful exploration of how they can be best supported in their role.
Hampshire and Isle of Wight Healthcare NHS FT
south_east
An independent investigation into the care and treatment of a … — Rec 4
NHS Somerset Clinical Commissioning Group must work with stakeholders to assess the impact of service changes on all groups of stakeholders, specifically patients and their families, and GPs. Particular attention must be given to evidencing an improvement in access to urgent Mental Health Act assessments.
south_west
Independent investigation into the care and treatment of Mr N — Rec 19
The Trust should assure itself that the perspective of families is included in care planning, and appropriate cultural awareness is applied when communicating with families.
london
Accepted
Independent investigation into the care and treatment of Mr N — Rec 18
The Trust must ensure that all families caring for young people in inpatient services are offered access to a carers assessment.
london
Accepted
An Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud … — Rec 5
Support NIHR research into: How caregiver concerns are raised, received, and acted upon.
north_east_yorkshire
Independent investigation: Sidney Waller, Manchester (2008) — Rec 11
The Trust should develop some good practice guidance on how to involve carers and relatives in investigations, based on the good practice that occurred in this case.
north_west
Independent investigation: Amina Ali, Sheffield (2004) — Rec S8
In addition to the above, SCT is encouraged to broaden its current audit tool for Supervision to allow staff to contribute ideas for improving the system of supervision and to describe elements that do not meet their needs as professionals. The clinical audit department might also consider increasing its sample …
north_east_yorkshire
Independent investigation: Wendy Pashley, Rotherham (2006) — Rec 5
As part of the Trust’s ongoing commitment to improving its approach to, and standard of client focused risk assessments, the Trust should consider conducting a survey of all of its staff to find out: what works well in the risk assessment process; what elements the staff feel need to be …
north_east_yorkshire
Independent investigation: Vincent Francis, Wells (2009) — Rec 3
The Trust should seek evidence and reassurance that GP and carer groups are consulted when policies are developed which are aimed at improving service delivery to young people with alcohol misuse problems.
south_west
Independent investigation: Lin & Megan Russell, Kent (1996) — Rec Paragraph 6.4
If it is practicable to do so, Mr Stone should be given an opportunity to consider this report on its completion. On conclusion of his appeal he should be given the opportunity to make representations to the Panel about any matter arising from the report. The Panel should then reconsider …
south_east
Independent investigation: Eshun Marnade Chattun, Springfield hospital Tooting (2003) — Rec 13
The John Meyer Ward team should continue efforts to improve services in light of the patient experience survey findings. Particular emphasis is needed to find ways of improving the range of activities for patients, particularly at evenings and weekends.
london
Independent investigation: Anthony Kellman, Brixton (1994) — Rec R1
WE RECOMMEND THAT the Terms of Reference of an inquiry such as this should require the Panel as a matter of principle to invite the primary and secondary victims and their relatives to contact the Inquiry Panel.
london
Independent investigation: Anthony Harrison, Andover (1998) — Rec 8
The Health Authority, PCGs, NHS Trusts, Social Services and partner agencies should develop a more systematic approach to the involvement of local mental health service users and carers in the planning and development of mental health services.
south_east
Independent investigation into the care and treatment provided to Mr … — Rec Recommendation 2
In light of the significant progress made the recommendation is that the Trust audits its current process within six months of the Independent Investigation report. This audit will be overseen by the commissioners of service and will specifically address: 1. The levels of family and service user uptake of the …
Devon Partnership NHS Trust
south_west
Accepted
Independent investigation into the care and treatment of Mr J — Rec R2
In terms of the impact of this action, the Trust should consider the available assurance to assist in this area, which may be through compliments, complaints or the National Inpatient Survey.
Mr J who committed a homicide in 2014. Mr J was in receipt of services from East London NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr J — Rec R1
In terms of the impact of this action, the Trust should consider the available assurance to assist in this area, which may be through compliments, complaints or the National Inpatient Survey.
Mr J who committed a homicide in 2014. Mr J was in receipt of services from East London NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr J — Rec R2
In terms of the impact of this action, the Trust should consider the available assurance to assist in this area, which may be through compliments, complaints or the National Inpatient Survey.
Mr J, published on 25 August 2020. Mr J was in receipt of services from South London and Maudsley NHS Trust
london
Accepted
Independent investigation into the care and treatment of Mr J — Rec R1
In terms of the impact of this action, the Trust should consider the available assurance to assist in this area, which may be through compliments, complaints or the National Inpatient Survey.
Mr J, published on 25 August 2020. Mr J was in receipt of services from South London and Maudsley NHS Trust
london
Accepted
An independent review into the independent sector provider One to … — Rec 3
Engagement should continue regularly with wider stakeholders to obtain comprehensive and honest feedback on implementation and to inform any changes to a service specification.
north_west
Independent investigation report into the care and treatment of Yusuf — Rec 4
Staff were unaware of the website resource Healthier Together which contains information leaflets and advice (for safety netting). • Parents should be directed to the Healthier Together website for written patient information. • Nursing and medical staff working in the paediatric UECC should be aware of this resource. Leaflets should …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation report into the care and treatment of Yusuf — Rec 5
Staff were unaware of the website resource Healthier Together which contains information leaflets and advice (for safety netting). • Parents should be directed to the Healthier Together website for written patient information. • Nursing and medical staff working in primary care should be aware of this resource. Leaflets should be …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 43
The Trust and the PCTshould carry out a survey of GPs, the CMHTs and other relevant front-line mental health staff to identify where recent developments in mental health services in the area have been successful and where there are still problems which need to be addressed. Both organisations should encourage …
london
Independent investigation: Angela Titley, Private Psych hospital, Redhill, Surrey (2004) — Rec R24
We recommend that the HC give urgent consideration to the ways in which it might better publicise its role, with a view to ensuring that members of the public who may have concerns about an independent hospital are aware that the HC exists; that it has a regulatory role; that …
south_east
Investigation into matters relating to Jimmy Savile at Leeds General … — Rec 26
The Trust should review how it seeks the views of a wider range of stakeholders in developing policies, and should ensure that all policies are patient centred. In doing so, it should draw best practice from other organisations within and outside the NHS (source: chapter ten).
Leeds Teaching Hospitals NHS Trust
north_east_yorkshire
An Independent Review into the care and treatment provided by … — Rec 1
The Trust must ensure that patient, family and carer voices are heard at every level of the organisation. The Trust must respond quickly when people experience difficulties with the services they receive and make lived experience voices central to the design, delivery and governance of its services. They have developed …
Greater Manchester Mental Health NHS Foundation Trust
north_west
An independent investigation into the care and treatment of a … — Rec 3
NHS Somerset Clinical Commissioning Group must assess the impact to relevant stakeholders of the actions completed by the Trust.
south_west
Independent investigation into the care and treatment of patient M … — Rec 97
Various methods of information sharing have been adopted, such as prison radio, poster campaigns and distributing leaflets and promotional materials. This should be a priority because prisoners report only patchy access to information, with particularly low levels of information on harm reduction such as keeping safe if using, and keeping …
east_of_england
Independent investigation into the care and treatment of Mr N — Rec 15
The Wells unit must ensure that all patient reported allegations of bullying are appropriately investigated, and safeguarding procedures instigated.
london
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 8a
Improve how women's, families' and communities' experiences and views are heard and acted on by optimising the implementation of the Perinatal Engagement Framework.
wales
Accepted
Scottish Fatal Accident Inquiries(1)
Detention investigations(2)
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R48
The safeguarding team should survey staff at Brook House regularly to ascertain their experience of and perspective on violence and bullying and its causes. (To be completed within 6 months)
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 41
In general, I believe that Boards in IRCs (as in prisons) need to develop a range of techniques for taking the temperature of an institution in addition to formal applications and walking the site. I think the idea of regular 'surgeries' could also be added to the list above, and …
Immigration Detention
Independent reviews(29)
Narey-Owers Foster Care Review — Rec 24
We recommend all local authorities use Bright Spots, or similarly to survey approaches regularly and systematically to measure children's experience of fostering relative to other local authorities.
Other
Clementi BBC Governance Review — Rec 6
the Charter should place on the BBC a duty to consult with the public both as consumers and as Licence Fee payers
Other
Harrington FDI Review — Rec 4
The new Investment Committee should work across government to propose further improvements to the UK business environment, informed by the investor feedback provided to the Review, summarised below.
Other
Harris Review: Deaths in Custody — Rec 98
During inspections, HMIP should ensure that they take account of the views of prisoners’ families on the prison regime.
Justice & Legal
Sayce Review — Rec 2g
The Department should work with user-led organisations to provide services and peer support for people using Access to Work. This could include assessment and delivery – so the process is fully informed by what others have found most helpful.
Other
Laming Review (Baby P) — Rec 18
Whether or not a national system is introduced, the Department for Children, Schools and Families should take steps to improve the utility of the Integrated Children's System, in consultation with social workers and their managers, to be effective in supporting them in their role and their contact with children and …
Other
Hampton Review — Rec 18
When designing new forms, all regulators should include a statement detailing how long they will take to complete and separating out: • the time taken to comprehend the form; • the time taken to gather the data; and • the time taken to fill and return the form. The forms …
Other
Farmer Review (Women) — Rec 18
A separate standardised visitor's survey to be developed for women's prisons. i. Each prison to survey regularly the women in their care, and families/significant others who visit to find out: • how many were able to attend family days and other forms of extended visits compared with how many wanted …
Justice & Legal
Wessely Review — Rec 95
The CQC should pay particular regard to obtaining patient (and carer) input from those who might find it difficult to articulate their views, including those in secure and out-of-area placements, those with learning disabilities or autism, children and young people.
Health & Social Care
Accepted
Morse Loan Charge Review — Rec 14
report to Parliament on its implementation of the Loan Charge before the end of 2020, drawing on input from their recently established Customer Experience Committee, representative bodies, charities focused on lower income individuals, and other professionals. This report should also address common themes arising from other recent reports, including from …
Other
Goldacre Review — Rec TRE 6
Rapidly scale over 18 months The following 18 months should be spent onboarding external users, iterating the platform, iterating detailed documentation for users, actively recruiting users, and adding features in response to user feedback. Proof of delivery should be in the form of outputs, code, and technical documentation, not PowerPoint …
Health & Social Care
Building Better Building Beautiful Commission — Rec 36
support design review but not from ‘on high’. Design review is an important tool for bringing specialist assistance to local authorities that they are not able to maintain permanently. Design reviews need to be empirically grounded and should take advantage of community engagement, visual preference evidence and consultation with local …
Building Safety
Building Better Building Beautiful Commission — Rec 9
permit a fast track for beauty. If a robust design policy, which is based on community engagement and which has been properly examined, has been established, the detailed planning application stage should be relatively straightforward. The focus should be on compliance with the site-specific design policy, whether contained in the …
Building Safety
Building Better Building Beautiful Commission — Rec 7
localise the National Model Design Code. We support the government’s proposal to publish a National Model Design Code, which will function as a template for local authorities to develop, their own codes in accordance with local needs and preferences and to support better urbanism and mixed use as described in …
Building Safety
Building Better Building Beautiful Commission — Rec 6
use provably popular form-based codes. Local planning authorities should develop more detailed design policy interventions, such as provably popular form-based codes and pattern books, as a basis for considering planning applications.21 We believe that form-based codes and non-negotiable infrastructure including green infrastructure (as with the Community Infrastructure Levy) are often …
Building Safety
Building Better Building Beautiful Commission — Rec 4
discover beauty locally. Local authorities, neighbourhood forums and parishes should be strongly encouraged to embed the national requirement for beauty and placemaking from the outset, before any decisions are made about allocating land or making development control decisions. What beauty means and the local ‘spirit of place’ should be discovered …
Building Safety
Narey Review of Children's Residential Care — Rec 19
I urge Ofsted to ensure that dialogue between homes and inspectors is the norm before, during and after inspection and that inspector performance assessment takes account of this requirement.
Other
Neurodivergence Task and Finish Group: report — Rec 2
Recommendation Two: Introduce a ‘commitment to listen’ to parents/carers and neurodivergent young people and recognise where schools do this well Whilst schools and teachers are responsible for and have expertise in educational needs and support strategies, parents/carers should be valued partners in the education of their children [6]. Parents are …
Health & Social Care
Dash Patient Safety Review — Rec 5
Bring together the work of Local Healthwatch, and the engagement functions of integrated care boards (ICBs) and providers, to ensure patient and wider community input into the planning and design of services. The statutory functions of Local Healthwatch relating to healthcare should be combined with the involvement and engagement functions …
Health & Social Care
Accepted
Francis Curriculum Review — Rec 6
Involves teachers in the testing and design of Programmes of Study as part of the drafting process. This must take into consideration the curriculum time that is available, ensuring the national curriculum is ambitious but teachable within a typical school timetable.
Education
Litchfield WCA Review Year 5 — Rec 15
The Department work with the new Provider to review the existing material available to improve both the quality and content of online resources available to those individuals about to go through a WCA. They should consider working with representative organisations to ensure that the information is both clear and accessible.
Employment & Work
Building Better Building Beautiful Commission — Rec 44
re-discover civic pride in architecture. New public sector buildings should be popular, and beautiful sources of civic pride. In addition to the changes set out above, it should be routine for public sector procurement process for new buildings or public realm schemes to: • State clearly in their aims that …
Building Safety
Building Better Building Beautiful Commission — Rec 40
count happiness and popularity. Council chief executives, chief placemakers, highways, infrastructure and planning teams should be set key targets and performance indicators which speak directly to the beauty and popularity of what is being permissioned, and to the effects on community well-being, health and sense of neighbourliness. Key targets and …
Building Safety
Building Better Building Beautiful Commission — Rec 12
move public engagement from analogue to digital. Despite some improvements, there remain huge opportunities to use digital technology more effectively to improve decision- making, option testing and to engage with a wider section of the community earlier in the plan-making and development process. The attractiveness or otherwise of the proposals …
Building Safety
Building Better Building Beautiful Commission — Rec 11
ensure public engagement, is wide, deep and early using tried and tested tools for engagement such as ‘Enquiry by Design’ as well as testing place and visual preferences more widely by using surveys. Democracy needs to move forward to the local plan phase. • Regulation 18 of the Town and …
Building Safety
Jackson Review — Rec 99
Judges and practitioners should be included in future development teams for individual court IT projects.
Other
Hampton Review — Rec 15
The review recommends that all regulators set up business reference groups on a sectoral basis and involve them at all stages when introducing a new form, including form design. The reference group should vet the design of forms.
Other
Dash CQC Review — Rec 5
Recommendation 5: continue to evolve and improve local authority assessments CQC has been clear that the assessment process for local authorities will evolve during baselining. It is now 9 months into the 2-year baselining period. CQC should consider feedback it has received, alongside the findings in this review, in order …
Health & Social Care
Wanless Review — Rec 16
The Boards of Strategic Health Authorities (StHAs) should include local patient and business representatives (6.83).
Health & Social Care
LGO / SPSO decisions(70)
21-017-107 — Bristol City Council
Summary: Miss X complains the Council incorrectly advised her to submit a non-material amendment (NMA) application for changes to existing planning permission which it then rejected, after it deemed the changes as material, incurring a £234.00 fee. There was no fault in the initial advice the case officer gave Miss …
LGO (Local Government & …
Planning
Upheld
Jun 2022
21-005-727 — Wakefield City Council
Summary: Mrs X complained the Council ignored her request for a reasonable adjustment leaving her unable to access the Council’s complaint process, causing her frustration and additional costs. We found the Council was at fault for not properly considering Mrs X’s request for a reasonable adjustment. We recommended the Council …
LGO (Local Government & …
Other Categories
Upheld
Mar 2022
21-014-987 — Derbyshire County Council
Mr X complained the Council failed to adequately consult with him and other residents around its decision to approve a cycling and walking scheme in his area.
LGO (Local Government & …
Transport And Highways
Upheld
May 2022
22-002-449 — Bath and North East Somerset Council
Summary: The Council gave Ms B confusing information about whether she could make a formal objection to a neighbourhood improvement scheme, and it did not always correctly handle its communication with her. However, I am persuaded that the Council has taken Ms B’s needs into account within its consultation process, …
LGO (Local Government & …
Transport And Highways
Upheld
Dec 2022
22-002-694 — London Borough of Hounslow
Summary: We will not investigate this complaint about allotment fees because part of the complaint is late and because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Other Categories
Jun 2022
22-004-305 — Reading Borough Council
Summary: We will not investigate Mrs X’s complaint about a storytelling event due to be held at the Council’s library. This is because the matter has not caused Mrs X a significant personal injustice.
LGO (Local Government & …
Other Categories
Jul 2022
23-019-467 — Westminster City Council
Summary: Mr X complains the Council is failing to provide him with enough support to meet his care needs. There was a period in 2023 when the Council did not respond to Mr X’s e-mails because they were going to a junk folder. The Council needs to apologise for the …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
23-015-068 — West Lindsey District Council
Summary: The Council properly investigated Mrs B’s reports of noise from her neighbours and problems with building work. The Council’s website was not clear that it has powers to tackle noise from premises under antisocial behaviour (ASB) legislation. This has not impacted on Mrs B as it is unlikely the …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2024
25-000-516 — Durham County Council
Summary: We will not investigate Ms X’s complaint about the Council’s response to a service request. The Council has already upheld Ms X’s complaint, apologised and taken steps to rectify its service delivery. Because these actions are appropriate and there are no wider public interest issues, it is not proportionate …
LGO (Local Government & …
Other Categories
Upheld
Apr 2025
24-021-182 — Brighton & Hove City Council
Summary: We will not investigate Ms X’s complaint about the Council’s handling of her complaint about antisocial behaviour from a neighbour. It is unlikely an investigation would lead to a different outcome or achieve what Ms X wants.
LGO (Local Government & …
Environment And Regulation
Jun 2025
201904682 — Fife Council
C complained about how the council handled and assessed a planning application. The planning application related to a proposal for an extension to an existing business premises and was approved by the council. C's own business premises are located nearby and C raised concerns about how the extension would impact …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
May 2021
25-011-216 — Ashfield District Council
Summary: We will not investigate this complaint about the way the Council carried out a public consultation. We have not seen enough evidence of fault in the Council’s actions.
LGO (Local Government & …
Other Categories
Dec 2025
201903741 — Scottish Water
C operated a bed and breakfast business from their home (the premises) and a number of years ago was identified as a gap site (a property where commercial activity is being conducted and should, therefore, be liable for commercial water charges, but that has not yet been registered for commercial …
SPSO (Scottish Public Se…
Water
Not Upheld
Oct 2021
25-012-768 — Darlington Borough Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Other Categories
Feb 2026
25-012-722 — Calderdale Metropolitan Borough Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Other Categories
Feb 2026
25-012-648 — City of York Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Other Categories
Feb 2026
25-015-563 — New Forest District Council
We will not investigate Mrs X’s complaint about how the Council considered her request for reasonable adjustments. The Council has agreed to apologise to Mrs X and make service improvements.
LGO (Local Government & …
Other Categories
Upheld
Feb 2026
21-009-014 — Buckinghamshire Council
Summary: Mrs X complained the Council refuse crew failed to return her garden waste bin to the collection point after emptying it. Mrs X says the Council’s actions cause her strain in retrieving the bin given her age. The Ombudsman found fault with the Council. The Council has already made …
LGO (Local Government & …
Environment And Regulation
Upheld
Mar 2022
22-000-115 — Tameside Metropolitan Borough Council
Summary: We will not investigate this complaint about changes the Council has made to its waste management strategy. This is because it is an issue that has affected all or most of the people in the Council’s area. We are unlikely to find fault in how the Council consulted about …
LGO (Local Government & …
Environment And Regulation
Apr 2022
22-001-975 — Birmingham City Council
We will not exercise discretion to investigate this complaint about Mr X’s complaint about the Council failing to help him evict a tenant whom it referred to him under a previous scheme. The complaint was received outside the normal 12-month period for investigating complaints. There is no evidence to suggest …
LGO (Local Government & …
Housing
May 2022
22-001-945 — Transport for London
Summary: We will not investigate this complaint about the outcome of a test the complainant took as part of his application for a private hire driver’s licence. This is because there is insufficient evidence of fault by the Authority, and he could bring his concerns about access to information to …
LGO (Local Government & …
Environment And Regulation
May 2022
22-001-767 — City of Bradford Metropolitan District Council
Summary: We will not investigate this complaint about Mr X’s business rates. The argument about how much business rates Mr X should pay could reasonably be raised in court. We cannot consider what happened in court.
LGO (Local Government & …
Benefits And Tax
May 2022
22-001-673 — London Borough of Croydon
Summary: We will not investigate this complaint about incorrect council tax bills. This is because the problem has been resolved and there is insufficient evidence of injustice. In addition, we cannot investigate a council when it is operating as a landlord.
LGO (Local Government & …
Benefits And Tax
May 2022
22-001-632 — London Borough of Haringey
Summary: We will not investigate this complaint about the handling of Mrs X’s housing application. The evidence suggests the Council properly reached its decision, so we cannot criticise the decision.
LGO (Local Government & …
Housing
May 2022
22-002-128 — Dorset Council
Summary: We will not investigate Mr X’s complaint about the Council’s handling of an alcohol licence application. This is because he had available appeal rights to the Magistrates’ Court to challenge the Council’s decision on the application which places the complaint outside our jurisdiction.
LGO (Local Government & …
Environment And Regulation
May 2022
22-002-302 — Northumberland County Council
Summary: We will not investigate this complaint about the Council’s decision to continue to treat Mr X as a vexatious complainant. This is because we are unlikely to find evidence of fault by the Council or injustice caused to Mr X sufficient to warrant an investigation.
LGO (Local Government & …
Other Categories
May 2022
22-002-205 — Swale Borough Council
Summary: We will not investigate this complaint about how the Council dealt with Mr X’s representations about a penalty charge notice as it would not be in the public interest to do so.
LGO (Local Government & …
Transport And Highways
May 2022
22-001-360 — London Borough of Merton
Summary: We will not investigate Ms X’s complaint the Council’s electoral register is not showing the date she moved into her property or first applied for the register thereby harming her credit rating. The Council has not caused Ms X an injustice and we cannot achieve the outcome Ms X …
LGO (Local Government & …
Other Categories
May 2022
22-001-345 — Bournemouth, Christchurch and Poole Council
Summary: We will not investigate this complaint that security guards at the recycling centre do not display their ID badges. This is because there is insufficient evidence of fault by the Council and insufficient evidence of injustice.
LGO (Local Government & …
Environment And Regulation
May 2022
22-000-928 — Cotswold District Council
Summary: We will not investigate Mr X’s complaint about the actions of refuse operatives and the Council in dealing with the issue as there is not enough evidence of injustice caused by fault to warrant investigation.
LGO (Local Government & …
Environment And Regulation
May 2022
21-016-303 — London Borough of Hounslow
Summary: We will not investigate this complaint about the Council’s refusal to approve Mr X’s application for a vehicle crossing. There is insufficient evidence of fault which would warrant an investigation.
LGO (Local Government & …
Transport And Highways
May 2022
21-015-761 — Leeds City Council
Summary: Ms X complained the Council failed to properly investigate her concerns about the allotment committee’s decision to evict her from her plot causing her to lose out financially and be the subject of harassment. The Ombudsman does not find fault with the Council.
LGO (Local Government & …
Other Categories
Not Upheld
Jun 2022
22-004-808 — Burnley Borough Council
Summary: We will not investigate this complaint about how the Council worked with a community group to create a new park. This is because the events happened too long ago and I see no reason why the complaint could not have been made sooner.
LGO (Local Government & …
Other Categories
Jul 2022
21-012-376 — Bolton Metropolitan Borough Council
Summary: Mr X complained the Council failed to maintain a hedge that backs onto his property. Mr X said the Council also misled him about its responsibilities. Mr X says this has caused him considerable upset and distress. We do not find fault with the Council’s approach to determining liability …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2022
22-006-973 — Havant Borough Council
Summary: We will not investigate Mrs X’s complaint about the Council missing some of her paid-for garden waste collections. There has been fault by the Council in it not completing all planned collections and it has offered a partial refund of the fee. There is not enough remaining injustice to …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2022
21-017-094 — Leeds City Council
Summary: Mr X complained that the Council repeatedly failed to collect his bins which were registered for an assisted collection. The Council accepts fault and has suggested a way forward. We have made recommendations to acknowledge the distress the Council’s fault has caused Mr X.
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2022
22-007-896 — Cheshire East Council
Summary: We will not investigate this complaint about the Council’s failure to respond to the complainant’s request for faded dog fouling stickers where he lives to be replaced. The Council has apologised for the delay to respond and offered to send replacement stickers for the complainant to put up.
LGO (Local Government & …
Environment And Regulation
Nov 2022
22-001-557 — Tamworth Borough Council
Summary: Ms S complains about the Council’s inaction in dealing with her reports of her neighbour making low frequency noise to annoy her. She also complains the Council decided to restrict her contact with it. The Ombudsman’s view is the Council has taken appropriate action to deal with Ms S’s …
LGO (Local Government & …
Environment And Regulation
Upheld
Nov 2022
24-001-381 — Kent County Council
Summary: Mr X complained about a Parking Charge Notice that a private enforcement agency, which the Council employs, issued. He says he paid for his parking, but it was not properly registered because of a faulty machine, and the Council has refused to resolve this. We have decided to end …
LGO (Local Government & …
Transport And Highways
Not Upheld
Sep 2024
23-000-466 — Rotherham Metropolitan Borough Council
Summary: X complained the Council failed to take effective action to protect them from noise and dust caused by construction work. We did not investigate this complaint further because it was unlikely to result in a finding of fault, a remedy for X or any other meaningful outcome.
LGO (Local Government & …
Planning
Not Upheld
Sep 2024
24-007-349 — Manchester City Council
Summary: We will not investigate Mr X’s complaint about a refuse operative being verbally abusive to him and his wife. We could not add to the Council’s investigation or achieve anything more.
LGO (Local Government & …
Environment And Regulation
Sep 2024
24-009-116 — Transport for London
Summary: We cannot investigate Mr X’s complaint about two penalty charge notices issued by Transport for London. This is because Mr X has used his right of appeal to London Tribunals.
LGO (Local Government & …
Transport And Highways
Sep 2024
24-008-711 — Transport for London
Summary: We will not investigate Mr X’s complaint about Transport for London’s handling of his representations against a penalty charge notice. This is because it would have been reasonable for Mr X to appeal to London Tribunals. We will not investigate TfL’s escalation of the case as it did not …
LGO (Local Government & …
Transport And Highways
Sep 2024
24-008-654 — London Borough of Southwark
Summary: We will not investigate Ms X’s complaint about the Council’s decision she is not eligible for a parking permit. This is because there is no sign of fault by the Council.
LGO (Local Government & …
Transport And Highways
Sep 2024
24-007-974 — London Borough of Haringey
Summary: We will not investigate this complaint about a Penalty Charge Notice. It was reasonable for Mr X to use his statutory right of appeal to a tribunal.
LGO (Local Government & …
Transport And Highways
Sep 2024
24-009-134 — Transport for London
Summary: We will not investigate Mr X’s complaint about a penalty charge notice issued by Transport for London. This is because Transport for London has accepted Mr X’s representations and cancelled the penalty charge notice and investigation would not achieve anything more for him.
LGO (Local Government & …
Transport And Highways
Sep 2024
24-008-854 — London Borough of Redbridge
Summary: We will not investigate Mr X’s complaint about a penalty charge notice issued by the Council. This is because the amount of the penalty charge paid is not significant enough to warrant investigation. Mr X also had a right of appeal to London Tribunals which it would have been …
LGO (Local Government & …
Transport And Highways
Sep 2024
24-007-197 — London Borough of Islington
Summary: We will not investigate this complaint about the Council’s failure to take enforcement action over a reported noise and neighbour nuisance. There is insufficient evidence of fault which would warrant an investigation.
LGO (Local Government & …
Environment And Regulation
Sep 2024
24-005-964 — Swale Borough Council
Summary: We will not investigate Miss X’s complaint about parking issues relating to her property. The complaint lies outside our jurisdiction because it is late and there are no good grounds to exercise discretion to consider it now.
LGO (Local Government & …
Transport And Highways
Sep 2024
24-007-861 — Cheshire East Council
Summary: We will not investigate Mr X’s complaint about charges for a replacement bin. There is not enough evidence of fault by the Council.
LGO (Local Government & …
Environment And Regulation
Sep 2024
Domestic Homicide Reviews(7)
West Lancashire — recommendation 15
West Lancashire Borough Council to ensure that information is available, to ensure tenants are aware to contact the Council, if they have problems when maintenance jobs are undertaken at their property.
West Lancashire Borough Council Housing Team
Norfolk — recommendation 35
That the University reviews the existing information provided on its website to ensure that there is a single, easily traced, and navigated pathway to make contact with concerns about a student 24 hours a day and that there is clarity about what anyone raising concerns can expect in terms of …
University of Manchester
The University of Manchester
Dorset — recommendation 2
Identify the mechanisms for the inclusion of the voice of survivors in the development and delivery of Dorset's DA work.
Dorset Council
Dorset County Council
Ceredigion — recommendation 15.3c
That the Regional VAWDASV Communication and Engagement Subgroup and VAWDASV’s survivor Engagement and communication framework, considers the merits of establishing a focus group of older person service users to examine issues around domestic abuse awareness raising and access to services.
Ceredigion County Council
Ceredigion County Council
Hillingdon — recommendation 13
Safer Hillingdon Partnership to carry out a review to establish service users’ and partner agencies’ views on the IDVA service being located in a statutory service. The experiences of other boroughs to be sought, and the findings to be acted on accordingly in relation to service delivery.
Safer Hillingdon Partnership
Bristol — recommendation 26
Renewed attempts should be made to find innovative ways to engage with families such as the victim's.
Carly’s School
Leicester — recommendation 2
The Home Office to consult with those affected by domestic homicide, in particular families, to hear their views on a standard for the publication and the sharing of learning from DHRs.
Home Office
Home Office