Quality and safety oversight
Failure to adequately assess, monitor, evaluate, and improve the quality and safety of services, hindering continuous improvement.
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.
449 inquiry recs
76 PFD reports
372 committee recs
467 CQC actions
8 ICIBI recs
6 PPO recs
16 IOPC recs
16 NAO recs
5 PHSO recs
8 IMB recs
2 IMB reports
12 detention investigation recs
8 PHSO decisions
35 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(449)— showing 50 strongest matches
R103 — Public learning disability performance dashboard within 12 months
Recommendation: A live dashboard of performance, quality and safety indicators within learning disabilities must be developed and made publicly available within 12 months of the publication of this report.
Response Pending
R84 — Learning disability service culture measure
Recommendation: RQIA needs to consider adopting a measure of service culture specific to learning disability services for use in its inspections. Such measures have already been developed for learning disability residential settings.
Response Pending
R83 — RQIA use of CCTV in inspections
Recommendation: The RQIA needs to reconsider whether to make use of CCTV when it is in operation in a service it is inspecting where concerns have been raised.
Response Pending
R82 — Risk-based inspection prediction
Recommendation: RQIA should consider developing a risk-based way of predicting which services are in difficulty. It is well known that certain aspects of services tend to be associated with abuse: service users who are vulnerable, who have few communication skills; service …
Response Pending
R81 — Expert clinical governance advisory function
Recommendation: The DoH should establish an expert clinical/social governance advisory function to support providers.
Response Pending
R79 — Board member learning framework
Recommendation: The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should be required to undertake an examined course in governance (including both financial and clinical/social care governance, including patient …
Response Pending
R78 — Audit committee implementation tracking
Recommendation: HSCT Board audit committees should consider all internal audit recommendations and require directorates to provide updates on implementation three months, six months and one year after the internal audit report is received, and three monthly thereafter if still not fully …
Response Pending
R77 — Triennial Board governance reviews
Recommendation: The DoH Permanent Secretary should commission triennial reviews of each Board’s collective performance in clinical and social care governance.
Response Pending
R76 — NED with clinical governance expertise
Recommendation: NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical or social care governance and be appointed as a senior independent director with that responsibility. The DoH should …
Response Pending
R75 — Executive Director of Clinical and Social Care Governance
Recommendation: There must be understanding of both individual untoward events but also (and more importantly) systems and trends. Creating and maintaining effective governance for complex systems requires specialist skills. While this is largely recognised within finance governance, only superficial consideration is …
Response Pending
R67 — Independent review of systemic abuse conditions
Recommendation: Where there is evidence or suspicion of widespread abuse involving multiple staff and residents, focusing solely on individual perpetrators is insufficient. An independent review of enabling conditions should be conducted separately from case-specific or PSNI investigations. This review must be …
Response Pending
R66 — Quarterly safeguarding file audit
Recommendation: A quarterly multidisciplinary audit of 10% of safeguarding files per ward or residential unit should be conducted. Findings must be integrated with incident data and reported to the Executive Team, NEDs and the Strategic Planning and Performance Group (SPPG).
Response Pending
R64 — Safeguarding dashboard with screening decisions
Recommendation: The dashboard should include the number of allegations reported, together with the screening decision (referral to the Adult Safeguarding Gateway, referral to the joint protocol or no further action). Particular scrutiny should be given to allegations of abuse by staff …
Response Pending
R62 — Monthly safeguarding dashboard
Recommendation: Metrics on both child and adult safeguarding processes should be reported monthly via a safeguarding dashboard, with the same visibility and status as monitoring elective surgery or emergency department waiting times. These metrics should be publicly available.
Response Pending
R48 — Holistic safeguarding governance review
Recommendation: HSCTs must review and improve governance of safeguarding to ensure that findings from different safeguarding investigations are considered holistically, synthesised and presented to the public part of a Board-level committee.
Response Pending
R45 — Incident trend analysis on board dashboards
Recommendation: Incident reports of any violent or aggressive behaviour by either people with learning disabilities and autistic people or staff should be analysed and trend data reported on every HSCT Board’s quality and safety dashboard. In private and third sector care …
Response Pending
R44 — Proactive quality assurance beyond complaints
Recommendation: Complaints alone are a poor indicator of quality of care, particularly in a vulnerable population such as those admitted to MAH. A low volume or absence of complaints does not necessarily indicate that care provided is good or satisfactory. Organisations …
Response Pending
R43 — Red-rated complaints shared with all NEDs
Recommendation: All complaints managed at corporate level and rated as red (using the red, amber and green (RAG) rating matrix) should be shared with all non-executive directors (NEDs) on the Board.
Response Pending
R36 — Seclusion as extraordinary intervention with serious event audit
Recommendation: Use of seclusion should be considered an extraordinary and exceptional intervention. Each intervention should be subject to a serious event audit, conducted by a professional outside the service provider’s learning disabilities services. This audit should be shared with the person’s …
Response Pending
R33 — Statistical process control charts
Recommendation: To ensure meaningful interpretation of these trends, all HSCTs should adopt statistical process control (SPC) charts, as developed by Walter Shewhart in 1939. SPC charts use calculated upper and lower control limits to distinguish between normal variation in a stable …
Response Pending
R32 — Balanced performance measures including restrictive practices
Recommendation: HSCTs should implement a comprehensive set of balanced performance measures across all services for people with learning disabilities, including those commissioned from third-party providers. These measures should include: Trends in the use of restrictive practices; Trends of aggressive behaviour incidents, …
Response Pending
R30 — NED champion for restraint reduction
Recommendation: HSCTs should appoint a non-executive director (NED) to act as a champion for restraint reduction, with a mandate to hold executive directors accountable for delivery.
Response Pending
R28 — Restraint Reduction Network principles
Recommendation: The Restraint Reduction Network identifies six principles to avoid the use of restrictive practice. While there is evidence that some Trusts have adopted these principles, further action is needed to ensure the principles are fully embedded. These principles must be …
Response Pending
R27 — RQIA assurance of property processes
Recommendation: RQIA should examine the provider organisation’s internal assurance processes and make recommendations where they are insufficient.
Response Pending
R23 — Regular property and finance compliance checks
Recommendation: All organisations taking responsibility for property and/or finance for people with learning disabilities and autistic people should institute regular checks of adherence to their policies. This includes local checks, corporate checks and periodic internal audit checks.
Response Pending
R15 — Independent care plan reviews
Recommendation: Care plans should be regularly evaluated to assess their impact on people’s wellbeing. This is the responsibility of the care team and should include formal, documented input from the service user themselves (where appropriate) and families. Additionally, there should be …
Response Pending
R14 — Restraint and seclusion observation records
Recommendation: Observation records detailing all use of restraint and seclusion should be completed by the individual observing. In HSCT facilities, if the observer is unregistered, a registered staff member should countersign the entry rather than create a second-hand record. In private …
Response Pending
R3 — Non-acceptance notification within three months
Recommendation: With the exception of Recommendations 88 and 89 (R88 & R89) any other organisation that does not accept a recommendation for which it is named as responsible, should write within three months of this report to the DoH Permanent Secretary …
Response Pending
R2 — Public acceptance of recommendations within six months
Recommendation: The DoH should indicate publicly within six months of this report which recommendations it accepts and those it does not accept (and why). This should include the recommendations for all organisations for which the DoH holds primary responsibility. In relation …
Response Pending
R1 — Implementation monitoring group
Recommendation: The implementation of the following recommendations should be monitored by the DoH and progress should be reported to the DoH Permanent Secretary. To ensure progress is made, an implementation consultation group, which should include service users and the relatives of …
Response Pending
64 — Welsh independent school standards update
Recommendation: The Welsh Government should: update the Independent School Standards as a matter of urgency; update the national minimum standards for boarding schools as a matter of urgency; legislate so that all residential special schools are judged against the quality standards …
Gov response: On 30 June 2022, the Welsh Government stated that it will amend and strengthen the independent school regulations, and that work is ongoing to draft the legislation. The Welsh Government also stated that it will …
Accepted
63 — Extend TRA jurisdiction to teaching assistants
Recommendation: The Department for Education should amend the Teachers' Disciplinary (England) Regulations 2012 to bring all teaching assistants, learning support staff and cover supervisors within the misconduct jurisdiction of the Teaching Regulation Agency. The Department for Education and the Welsh Government …
Gov response: On 30 June 2022, the UK government stated that anyone undertaking teaching work can be referred to the Teaching Regulation Agency (TRA) and this could include teaching assistants and learning support staff. The TRA does …
Accepted in Part
60 — Independent school governance standards
Recommendation: The Department for Education and the Welsh Government should: amend the Independent School Standards to include the requirements that there is an effective system of governance, based on three principles of openness to external scrutiny, transparency and honesty within the …
Gov response: On 30 June 2022, the UK government stated that it agreed with the first two points of the recommendation in principle. It stated that it intended to consult on revised Independent School Standards in 2023 …
Accepted in Part
59 — National LADO standards
Recommendation: The Department for Education and the Welsh Government should: introduce a set of national standards for local authority designated officers in England and in Wales to promote consistency; and clarify in statutory guidance that the local authority designated officer can …
Gov response: On 30 June 2022, the UK government stated that it was considering the scope and timetable for a review of the statutory guidance Working Together to Safeguard Children. It stated that it will consider revised …
Accepted in Part
58 — Residential schools inspection and guardians registration
Recommendation: The Department for Education and the Welsh Government should: require all residential special schools to be inspected against the quality standards used to regulate children's homes in England and care homes in Wales; reintroduce a duty on boarding schools and …
Gov response: On 30 June 2022, the UK government stated that it was still of the view that the best way to protect children in residential special schools was to strengthen the National Minimum Standards (NMS), and …
Accepted in Part
50 — Independent validation of Catholic audit programme
Recommendation: The Catholic Safeguarding Advisory Service should have the effectiveness of its audit programme regularly validated by an independent organisation which is external to the Church. These independent reports should be published.
Gov response: On 30 September 2021, the Catholic Council for the Inquiry stated that the Catholic Safeguarding Standards Agency (CSSA) Board is committed to the independent verification of its audit processes, and would undertake a formal process …
Accepted
49 — Catholic non-compliance framework
Recommendation: The Catholic Bishops' Conference of England and Wales and the Conference of Religious should publish a clear framework for dealing with cases of non-compliance with safeguarding policies and procedures. That framework should identify who is responsible for dealing with issues …
Gov response: On 30 September 2021, the Catholic Council for the Inquiry stated that the trustee bodies of all Catholic dioceses and religious orders were invited to subscribe to the Catholic Safeguarding Standards Agency. The Catholic Safeguarding …
Accepted
47 — Catholic lead clergy for safeguarding
Recommendation: The Catholic Bishops' Conference of England and Wales and the Conference of Religious in England and in Wales should each nominate a lead member of the clergy for safeguarding to provide leadership and oversight on safeguarding matters to their respective …
Gov response: On 30 April 2021, the Catholic Council for the Inquiry stated that the role description for the Lead Bishop for the Catholic Bishops' Conference of England and Wales was approved and Bishop Paul Mason was …
Accepted
46 — Church independent external safeguarding audits
Recommendation: The Church in Wales should introduce independent external auditing of its safeguarding policies and procedures, as well as the effectiveness of safeguarding practice in dioceses, cathedrals and other Church organisations. Audits should be conducted regularly and reports should be published. …
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that it remained committed to their programme of five-yearly independent audits. The joint …
Accepted
FR-2 — Child Protection Authorities
Recommendation: The Inquiry recommends that the UK government establishes a Child Protection Authority for England and the Welsh Government establishes a Child Protection Authority for Wales. Each Authority's purpose should be to: improve practice in child protection; provide advice and make …
Gov response: We accept the need for a stronger safeguarding system. We will ensure the relevant actions included within our reform programme, Stable Homes, Built on Love, fulfil this recommendation.
Accepted in Part
8 — Expand Ofsted powers for unregistered settings
Recommendation: The government should introduce legislation to: change the definition of full-time education, and to bring any setting that is the pupil's primary place of education within the scope of the definition of a registered educational setting; and provide the Office …
Gov response: On 2 March 2022, the UK government stated that in 2020 it had consulted to legislate to amend the registration requirements for independent education settings. It confirmed that it had considered responses to the consultation …
Accepted in Part
7 — Catholic complaints policy with escalation process
Recommendation: The Catholic Bishops' Conference of England and Wales and the Conference of Religious should publish a national policy for complaints about the way in which a safeguarding case is handled. The policy should deal with communication with complainants during the …
Gov response: On 30 April 2021, the Catholic Council for the Inquiry stated that a framework and template for complaints was ratified by the Bishops. The framework and template include the need for clear communication between the …
Accepted
MACP-5 — Apply OFSTED-like standards to Police Service inspections for improved quality and reporting
Recommendation: That principles and standards similar to those of the Office for Standards in Education (OFSTED) be applied to inspections of Police Services, in order to improve standards of achievement and quality of policing through regular inspection, public reporting, and informed …
Unknown
MACP-3 — Grant Her Majesty's Inspectors full powers to inspect all Police Services.
Recommendation: That Her Majesty's Inspectors of Constabulary (HMIC) be granted full and unfettered powers and duties to inspect all parts of Police Services including the Metropolitan Police Service.
Unknown
BRIS-73 — Grant Council powers to enforce good regulation principles and consistent professional body behaviour
Recommendation: The Council for the Regulation of Healthcare Professionals should have formal powers to require bodies which regulate the separate groups of healthcare professionals to conform to principles of good regulation. It should act as a source of guidance and of …
Unknown
BRIS-72 — Prioritise establishing statutory Council for Regulation of Healthcare Professionals with broad membership
Recommendation: The Council for the Regulation of Healthcare Professionals should be established as a matter of priority. It should have a statutory basis. It should report to Parliament. It should have a broadly-based membership, consisting of representatives of the bodies which …
Unknown
BRIS-71 — Establish a single body to coordinate all healthcare professional regulatory bodies
Recommendation: In addition, a single body should be charged with the overall co-ordination of the various professional bodies and with integrating the various systems of regulation. It should be called the Council for the Regulation of Healthcare Professionals. (In effect, this …
Unknown
BRIS-70 — Establish single regulatory bodies for each distinct healthcare professional group
Recommendation: For each group of healthcare professionals (doctors, nurses and midwives, the professions allied to medicine, and managers) there should be one body charged with overseeing all aspects relating to the regulation of professional life: education, registration, training, CPD, revalidation and …
Unknown
HIDD-39 — Urgently introduce independent monitoring and auditing for all safety-related work
Recommendation: BR shall introduce monitoring and independent auditing systems in all safety-related aspects of work, in particular the S&T Departments, with the greatest urgency, in advance of Total Quality Management as an aid to good management.
Unknown
HIDD-38 — Urgently use outside consultants to review safety management and communication issues
Recommendation: The Court endorses the use of outside consultants to review safety management issues within BR and recommends that the consultants proceed with their programme with the greatest urgency looking particularly at problems of communication up and down the organisation.
Unknown
Prevention of Future Deaths reports(76)— showing 50 strongest matches
Walter Gordon Powley
Concerns: Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.
Response (CQC): The CQC acknowledges the incident and will share the report's findings within the organisation. They are exploring ways to work more closely with the HSE and ensuring their new inspection …
Response (Health Safety Executive): HSE will raise concerns about assessing risks from hot surfaces and pipe-work at the next GB Social Care Partners Forum meeting, scheduled for February 2014. They will also share the …
Response (RNHA): The RNHA acknowledges the risk and states they regularly advise members of their responsibilities under the Health & Safety at Work Act, particularly regarding covering radiator pipes. They will continue …
Responded
Kathleen Rosemary Dixon
Concerns: Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.
Response (Department of Health): The Department of Health acknowledges the concerns raised about mental health assessments at Cumbria Partnership NHS Foundation Trust and outlines existing measures and guidance in place to improve patient safety …
Overdue
Mary Waldron
Concerns: Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues during ambulance transfer also posed a risk.
Overdue
Derrick Rivers
Concerns: The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Overdue
Clive Clinton
Concerns: A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior management and placing residents at risk of harm.
Overdue
Peter White
Concerns: Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed opportunities for critical interventions. No audit system was in place for chart accuracy.
Overdue
Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer
Concerns: Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international trial results, hinder optimal patient care.
Response (NHS England): NHS England is reviewing service specifications, establishing a national expert group for oncology, enhancing reporting to the BSBMT registry, and commissioning its quality surveillance team to assure changes in governance.
Responded
Edwin Thompson
Concerns: A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing pain, especially if it suggests a cardiac issue.
Overdue
Huseyin Erdogan
Concerns: Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, raising concerns about preventing future deaths.
Overdue
Maurice Cowling
Concerns: Despite the rarity of deaths from certain medical procedures, three fatalities occurred within a short period, two within the Trust, indicating a potential systemic issue.
Response (Northern Lincolnshire Goole NHS Trust): The Trust conducted a patient safety review of three cases and concluded that the complications were managed appropriately and existing arrangements are adequate. They state no further specific actions have …
Responded
Kathleen Neville
Concerns: The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in other Health Boards without such a policy.
Overdue
Amanda Ellams
Concerns: Substandard medical record-keeping, inadequate oxygen saturation monitoring, unsafe patient discharge, and a "flawed" unanswered out-of-hours district nursing telephone system collectively contributed to significant care failures.
Response (Response Alexandra Hospital): The hospital-wide completion of training on documentation and legal aspects for patient records was 95%, and further documentation training has been scheduled; nursing staff will be notified that nursing notes …
Overdue
Adrian Smith
Concerns: A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another hospital, highlighting a lack of systems to ensure specialist advice is implemented.
Response: The Trust will change the communication process for specialist radiological investigation queries by having the consultant radiologist speak directly with the senior neurosurgeon. A standard operating procedure (SOP) will be …
Overdue
Angela Brealey
Concerns: The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review process failed to identify several treatment concerns.
Response (South Staffordshire and Shropshire Healthcare NHS Trust): The Trust has reviewed and amended its Serious Incident Review process and now employs a full-time Serious Incident Review Co-ordinator and Administrator. Reports now go through an additional governance process, …
Overdue
Harry Gill
Concerns: The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.
Response (NHS England): NHS Pathways has amended the vomiting questions to be more specific, focusing on the nature of the vomit and the presence of coffee ground-like material. They have also enhanced the …
Responded
Martyn Watkins
Concerns: Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and facility safety on Aspen Ward are identified and addressed.
Response (CQC): The Trust had learnt from the death and implemented changes to manage future risks on Aspen Ward, though details of changes not provided in this extract.
Overdue
Norman Beard
Concerns: Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded the patient's deteriorating condition.
Overdue
Barry Thompson
Concerns: The patient's high-priority triage was not followed by timely review by a doctor or antibiotic administration per national standards, the NEWS score was not actioned, and there were issues managing a diabetic patient's monitoring and basic needs, along with inaccurate and incomplete record-keeping.
Overdue
Helen Millard
Concerns: The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, pose an extreme risk and should be categorized as "red" for urgent elimination.
Overdue
Doreen Willis
Concerns: Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC to review its inspection practices in light of these findings.
Response (Torbay and South Devon NHS Trust): The trust summarises the key learning outcomes from the agency review, pertaining to medicine management policies and processes for care homes. It references NICE guidance and the Electronic Transfer of …
Responded
Sam Crick
Concerns: Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.
Response (Barking Havering and Redbridge University Hospitals NHS Trust): The Trust will review externally reported deaths weekly as part of a Morbidity and Mortality session to identify lessons and feedback to referring hospitals, as part of the ongoing SIR …
Response (CQC): The CQC has requested written confirmation and evidence from Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) regarding actions taken following the death and any additional actions they intend …
Response (NHS England): NHS England will work with the Society of British Neurological Surgeons (SBNS) and the Royal College of Emergency Medicine to produce and distribute a guidance statement nationally within the next …
Responded
David Lindsey
Concerns: The family contended that the trust did not follow NICE guidelines for cancer screening, referrals, diagnosis and treatment, and that the trust did not follow its own policies and guidelines.
Overdue
Brian Betterton
Concerns: Product recalls for items like fuse boxes are ineffective because end-users are often untraceable, as professional purchasers are not required to log installation locations or end-user details.
Response (Department for Business Energy Industrial Strategy): The Department for Business, Energy & Industrial Strategy set up the Working Group on Product Recalls and Safety in October 2016, which published recommendations on improving recalls and reducing fires …
Responded
Sarah Kiff
Concerns: GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results were inadequate.
Response (Stonefield Street Surgery): The practice has produced annual audit reports around new cancer diagnoses for several years; the practice has a new written policy around methodology for undertaking HVS and the recording of …
Responded
Elaine Bradbrook
Concerns: Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal investigation or learning by the trust contributed to serious concerns.
Response (United Lincolnshire Hospitals NHS Trust): United Lincolnshire Hospitals NHS Trust acknowledges communication issues and historical problems with their Serious Incident (SI) process. They have made significant improvements to the SI process in the last 12 …
Responded
David Sketchley
Concerns: The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.
Response: The CQC is gathering evidence into this matter with a view to deciding whether there has been a failure by BUPA and/or the Registered Manager to comply with the Health …
Overdue
Neville Welton
Concerns: The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.
Response: The Health Board is establishing weekly meetings for senior staff to review incidents, track progress of investigations, and ensure timely action plan implementation, commencing July 12th, 2018. They will also …
Overdue
Lewis Colgan
Concerns: Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack of robust processes for CPA meetings and an incomplete Root Cause Analysis further raised concerns.
Overdue
Ester Wood
Concerns: Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, despite repeated prior warnings.
Overdue
Margaret Evans
Concerns: Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.
Overdue
Ruth Whitmore
Concerns: Issues included unclear responsibility and lack of awareness for nurses in charge, coupled with an inadequate initial investigation into an incident, which failed to thoroughly interview staff or analyse events.
Overdue
Sophie Bennett
Concerns: The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.
Overdue
Tom Cribley
Concerns: Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed administration of crucial antibiotics for sepsis, issues previously identified by CQC.
Overdue
Jean Cutler
Concerns: The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and an inadequate post-incident investigation with unaddressed systemic issues and incomplete risk assessments.
Response (Cole Valley Nursing Home): New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed, considering internal and external risk factors. A new competent, experienced and dynamic manager who will provide …
Responded
Kathleen Smith
Concerns: Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.
Response (Coed Duon Care Home): Coed Duon Care Home has implemented several changes, including SALT training for staff, designation of two Dysphagia champions, creation of a diets and fluids consistency file for each resident in …
Responded
Daniel Williams
Concerns: Deficient fundamental nursing care on a general ward led to patient deterioration, exacerbated by a flawed C-diff infection investigation process that failed to examine initial care failures on the transferring ward.
Response (Guys and St Thomas NHS Trust): The Trust's C-diff Action Group reviewed the Trust's C-diff investigation process and revised it to include a stage to check whether the mandatory infection control data forms need to be …
Responded
Ben Haddon-Cave
Concerns: Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection reporting, led to a lack of oversight and repair.
Response (Network Rail): • A National Safety Bulletin will be issued to all Off Track teams, which are the Network Rail maintenance teams that carry out boundary inspections. • The National Safety Bulletin …
Responded
Pamela Evans
Concerns: Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack of audit, limited CCOT authority, incorrect NEWS scoring, and the Trust's failure to identify these issues.
Response (Bedford Hospital NHS Trust): Bedford Hospital NHS Trust will ensure assessments and patient observations are carried out. The post falls protocols and level of escalation will be reviewed and there will be Shared learning …
Responded
Evelyn Swift
Concerns: The medical group lacked safe procedures for triaging patients, allocating home visits, providing urgent clinical advice, documenting calls, and ensuring sufficient clinical capacity; they also lacked processes to review significant events and learn from them.
Overdue
Gillian McKinlay
Concerns: There was no clear responsibility for A&E patients' overall care, and mandated clinical reviews for high EWS scores did not occur or were escalated. The Trust's serious incident investigation was inadequate, failing to address key issues or audit improvements.
Overdue
Frank Medley
Concerns: The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.
Response (Royal Blackburn Teaching Hospital): Royal Blackburn Teaching Hospital has established a core group to oversee implementation of an action plan addressing concerns regarding detection of adverse outcomes, review of the case, and radiology practices, …
Responded
Elizabeth Robinson
Concerns: Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess patient fall risk correctly, and were unaware of learning opportunities.
Response (Aneurin Bevan University Health Board): Aneurin Bevan University Health Board has established a Ysbyty Ystrad Fawr (YYF) Health Care Support Worker (HCSW) pool in September 2020 to support enhanced care levels. The Corporate Serious Incident …
Responded
Rachel Johnston
Concerns: The care home failed to adequately investigate nurse failings or report them to the NMC for over two years, and lacked proper policies for identifying, investigating, or suspending staff misconduct.
Response (Holmleigh Care Homes Ltd): Following a death, the care home introduced training for all nurses and reviewed its policies. They have since implemented the Staff Retention policy to ensure agency workers under investigation do …
Overdue
Pauline Brumfitt
Concerns: The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and neglecting timely reporting or investigation of incidents.
Response (Anchor Hanover Group): Anchor Hanover Group has reviewed and updated training, policies and procedures, introduced more formal triage arrangements, additional handover guidance, and improvements to Care Quality Indicators.
Overdue
Kyle Hurst
Concerns: The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, thereby putting lives at risk.
Response (BCUHB): BCUHB is considering adopting the SNAP protocol for paracetamol overdose treatment but requires local review and approval. The Health Board is reviewing historic action plans from serious incident investigations and …
Responded
Susan Merton
Concerns: The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, leading to ongoing risks to patient lives.
Response (BCUHB): BCUHB changed its serious incident process in April 2021, requiring all investigation reports to be submitted for scrutiny and approval at an Incident Learning Panel. The Health Board is tracking …
Overdue
Philip Ellis
Concerns: The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no serious incident review conducted into these supervision failures.
Response (Free the Way): Free the Way has introduced measures including escorting clients returning from relapse to collect belongings, searching all property, and restricting unaccompanied leave. Clients entering treatment will be monitored closely and …
Responded
Emma Burbury
Concerns: There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding record access. Patients were also discharged too readily for missed appointments without considering other support services.
Response (Cornwall Partnership): The Trust is contributing to the implementation of a system-wide Dual Diagnosis policy and will explore improvements to information sharing between partner organisations. Community Mental Health transformation work is underway …
Response (NHS Kernow Clinical Commissioning Group): NHS Kernow will provide funding for read-only access to We Are With You (WAWY) notes for CMHT staff at CFT. They are engaging with CFT regarding discharge processes and will …
Responded
Darrell Devlin
Concerns: Over-reliance on remote drug and alcohol service contacts without in-person assessments or drug testing led to inaccurate client assessment, risking harm from excessive dosage or polydrug exposure.
Response (Humankinds): Humankinds, the incoming provider of Addictions Services within Cumbria, describes actions already taken since taking over the service, including weekly provider meetings, clinical handover for high-risk cases, data transfer of …
Response (Greater Manchester Mental Health NHS Foundation Trust): Greater Manchester Mental Health (GMMH) acknowledges the concerns and apologizes, highlighting that the death occurred during the COVID-19 pandemic, and refers to a meeting with the new service provider, Humankind, …
Responded
Rebecca Begg
Concerns: The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support workers in client meetings, with no dedicated time for staff to read care plans.
Response (Heathcotes Group): Full incident reviews are implemented and the Clinical team now has involvement to understand the root cause and offer different support methods. The internal governance and quality assurance procedures have …
Overdue
Select committee recommendations(372)— showing 50 strongest matches
#3 —
Recommendation: We welcome the programme’s devolved design and recognise the government’s view that it appropriately balances national oversight with local flexibility. We are reassured that extensive performance monitoring is part of CtW, and that there is also a comprehensive evaluation programme …
Response Pending
#51 —
Recommendation: GBE and other public buyers must ensure that solar procurement decisions are made on the basis of independent assessments and not rely solely on the SSI to provide assurance of supply chains. (Recommendation, Paragraph 256)
Gov response: The Government welcomes the work of the Solar Stewardship Initiative (SSI) in promoting transparency and accountability within the solar supply chain through the use of assessments driven by independent audits. However, procurement decisions are not …
Accepted
#35 —
Recommendation: Enabling full cross-border enforcement will only be effective if licensing authorities have the capacity and incentives to undertake it. The government should address the current mismatch between enforcement responsibilities and funding by enabling licensing authorities to recover the costs of …
Response Pending
#34 —
Recommendation: We welcome the minister’s statement that the government wants licensing authorities to be able to take enforcement action against all the taxis and PHVs operating in their area. We look forward to the government’s forthcoming legislation setting out a clear …
Response Pending
#33 —
Recommendation: Many licensing authorities lack the resources and capacity to carry out effective enforcement. Enforcement officers are not able to take action against all taxi and private hire activity in their area. Cooperation between licensing authorities can be a positive step …
Response Pending
#32 —
Recommendation: The introduction of national standards should be accompanied by a single national complaints and incident reporting portal for taxi and private hire services. It should be digitally inclusive, route reports to the responsible authority, and include clear service standards for …
Response Pending
#31 —
Recommendation: Complaints and incident reporting arrangements are fragmented. In some areas they are difficult for passengers and drivers to navigate, reducing transparency and weakening accountability. (Conclusion, Paragraph 112)
Response Pending
#22 —
Recommendation: National standards should set a clear benchmark for licensing processing times, covering applications, renewals and variations, and require all licensing authorities to publish performance against that benchmark in a consistent format. (Recommendation, Paragraph 86)
Response Pending
#19 —
Recommendation: We recognise that mandating in-vehicle CCTV across the sector would be a significant, and in some quarters, controversial step. However, we heard substantial evidence about its potential to strengthen safety for both passengers and drivers, and we consider that evidence …
Response Pending
#10 —
Recommendation: The overwhelming majority of drivers uphold high standards and play an essential role in keeping communities moving safely. However, the system needs to provide a robust safety net for the protection of passengers and drivers. Safety standards must be absolute …
Response Pending
#5 —
Recommendation: The government’s proposal to move responsibility for licensing to local transport authorities may have advantages in terms of improving operational capacity, and the ability of transport authorities to better integrate taxis into their transport plans and brand accordingly. However, we …
Response Pending
#4 —
Recommendation: We urge the department to bring forward a clear plan to curtail the extensive practice of out-of-area working and create greater incentives for drivers to license in the locality in which they operate. This will enable local licensing authorities to …
Response Pending
#3 —
Recommendation: Out-of-area working is now a widespread feature of the taxi and private hire vehicle market. We recognise the strength of concern about its impact on standards, local accountability and public confidence. We also acknowledge that outright prohibition would be impractical. …
Response Pending
#2 —
Recommendation: We are pleased that the government has set out plans for legislation to modernise and consolidate the licensing framework for taxis and private hire vehicles. We urge the government to use the Law Commission’s 2014 draft bill and the report …
Response Pending
#24 —
Recommendation: The Department acknowledged that it had prioritised throughput— processing cases quickly—at the expense of consistent decision-making. With hindsight, that had been the wrong thing to do. It had been done for the right reasons—because the Department wanted to get the …
Response Pending
#22 —
Recommendation: In the written evidence we received, people described opaque and inconsistent decision-making, painting a picture of an arbitrary and unreliable system. They stated that support was reduced or removed without a clear rationale, change in need, and sometimes without warning. …
Response Pending
#26 —
Recommendation: The Government should seek to provide a joined-up subsea cables function providing a centralised point of contact for industry and international partners. This body should co-ordinate, not duplicate, cross-government work—bringing together departments and agencies covering subsea infrastructure operations, policy, security, …
Gov response: The Government partially agrees with this recommendation. We agree with the Committee on the importance of a centralised, cross-government function to support coordination on subsea cable security policy. However, we do not think that expanding …
Partially Accepted
#41 —
Recommendation: His Majesty’s Inspectorate of Prisons is responsible for inspecting the conditions and treatment of prisoners in England and Wales, with one of their inspection ‘expectations’ explicitly highlighting the importance of prisoners interacting with staff who are able to implement culturally …
Response Pending
#21 —
Recommendation: The Department told us it is developing an ‘Ajax 2’ package of upgrades, including composite rubber tracks and automatic track tensioners, as a technical solution which would reduce the need for soldiers undertaking the maintenance checks. These modifications are intended …
Response Pending
#20 —
Recommendation: The Department told us that it had no safety concerns about Ajax provided it was operated and maintained correctly within its design parameters. It then asserted that the incident during the exercise occurred because the vehicles had not been operated …
Response Pending
#19 —
Recommendation: The Department said that for our soldiers to develop and maintain the skills they require to operate on armoured vehicles, it needs to get them back on those vehicles as quickly as possible. However, it asserted that the safety of …
Response Pending
#18 —
Recommendation: Our predecessor Committee first reported on the failings of the Ajax programme in June 2022. It was told that the Army’s trials team had first raised concerns about vibrations in late 2019, and the Department rightly described it as “unforgivable” …
Response Pending
#20 —
Recommendation: NHSE informed us that there are also a number of broader developments which may affect service provision for frailty including a forthcoming modern service framework, new funding models for ICBs, a frailty improvement collaborative involving seven sites around the country, …
Response Pending
#19 —
Recommendation: NHSE informed us that it was establishing a national frailty dashboard which will take into account the range of interventions that NHSE expects ICBs to have in place. It noted that it does not intend to publish what it considered …
Response Pending
#14 —
Recommendation: NHSE also told us that it was about to write to ICBs, as part of the framework for neighbourhood health, with the key requirements that ICBs need to have in place next year around enabling better, more appropriate care for …
Response Pending
#13 —
Recommendation: NHSE told us that it is working to improve accountability and that, in the future, it intends to hold ICBs to account for commissioning against the modern service framework and expects there will be data from its national frailty dashboard …
Response Pending
#12 —
Recommendation: NHSE has set requirements for ICBs and GPs to provide health services that aim to assess and support people living with moderate and severe frailty.25 NHSE considers that ICBs are responsible for managing and measuring performance of many of the …
Response Pending
#6 —
Recommendation: We remain deeply concerned that cuts to ICBs are insufficiently thought through and will undermine their ability and capacity to carry out their functions. It is unclear what oversight roles ICBs will retain under NHSE’s plans to make them into …
Gov response: The government agrees with the Committee’s recommendation. consider risk appetite and tolerance for programmes in the current net zero R&I portfolio as set out in the Delivery Plan and develop an overall government risk appetite …
Response Pending
#19 —
Recommendation: The final bill must include provisions to establish a new, independent public body as the Regulator for property managing agents, with enforcement powers. This must include powers for the Regulator to issue fines or revoke licences of managing agents who …
Response Pending
#55 —
Recommendation: The Home Office should conduct a full review of its management of Covid-19 impacts on asylum accommodation and immigration detention in conjunction with its providers and other government departments. It should evaluate the impact of the temporary measures put in …
Gov response: The Government is grateful for the committee’s report and we remain committed to supporting those in our accommodation and those detained in our care, appropriately throughout this changing period. However, we do not believe that …
Under Consideration
#48 —
Recommendation: We urge the Home Office urgently to review the way Mears has been operating during the pandemic, to consider its poor management of service users’ welfare, and the wider public health consequences of its approach.
Gov response: 18 Home Office preparedness for COVID-19 (coronavirus): institutional accommodation: The Government expects the highest standards from all of our contractors and we work closely with asylum accommodation providers to monitor and ensure they continue to …
Under Consideration
#8 —
Recommendation: Similarly, procuring and distributing PPE involved a range of bodies, including the Department, Public Health England, local NHS providers and care homes, yet until the appointment of Lord Deighton in mid-April no one took the lead in making sure there …
Gov response: 1.1 The government agrees with the Committee’s recommendation. Recommendation Implemented 1.2 Information on the department’s COVID-19 Battle Plan, including the then senior responsible officers, was shared with the Comptroller and Auditor General on 5 June …
Not Addressed
#5 —
Recommendation: Staff in health and social care cannot be expected to be ready to cope with future peaks and also deal with the enormous backlogs that have built up unless they are managed well. We are deeply concerned about the frontline …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Recommendation Implemented 5.2 The department has published wellbeing guidance for all those working in adult social care, providing key advice and resources on maintaining mental wellbeing and …
Not Addressed
#44 —
Recommendation: It is not clear exactly which Government department or agency is ultimately responsible for coordinating border policy. Evidence from the Home Secretary suggested important roles for the Department of Health and Social Care, Public Health England and the Department for …
Gov response: The regulations were first signed by the Secretary of State for Health and Social Care are part of a coherent effort across the whole of the UK to tackle COVID-19 and protect the lives and …
Under Consideration
#1 —
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Ministry of Justice and HM Prison & Probation Service on improving the prison estate.1
Gov response: 1. NHS resilience and recovery – Lee McDonough, DHSC; Ruth May, Chief Nursing Office for England 2. Social care resilience including workforce and minimising transmission – Michelle Dyson, DHSC 3. Supply and distribution of key …
Under Consideration
#19 —
Recommendation: The Committee notes the strong progress the PHSO has made in delivering against this objective and informing discussions in the international Ombudsman community. The Committee looks forward to hearing of further progress in this area.
Not Addressed
#19 — Home Office contracts for migrant accommodation lack specified penalties for safeguarding failures.
Recommendation: The Home Office told us that health and welfare of migrants was “baked into” the way that it runs the sites and the contracts with suppliers. It said there were clear key performance indicators (KPIs) on accommodation being safe and …
Gov response: 3.12 The government agrees with the Committee’s recommendation. Target implementation date: October 2024 for the previous quarter, continuing quarterly. 3.13 Asylum, Accommodation Support Contracts (AASC) provide a mechanism for application of service credits if provider …
Accepted
#42 — Women's health hubs require national evaluation to ensure benefits and multi-service provision.
Recommendation: It is positive to hear that many of the leaders in the ICBs are focusing their hubs on disadvantaged groups. While local ownership, management and decentralisation of the hubs is important to meet local needs, regular national-level evaluations are also …
Gov response: We are committed to moving towards a neighbourhood health service, with more care delivered in local communities, to identify and address problems earlier and closer to home. Women’s health hubs are an example of this …
Not Addressed
#40 — Commission NICE to develop and disseminate comprehensive guidelines for all reproductive health conditions, monitoring adherence.
Recommendation: The Department of Health and Social Care and NHS England should commission NICE to develop comprehensive guidelines for all reproductive health conditions. Those guidelines should be communicated to GPs and made accessible to patients through the NHS website to allow …
Gov response: We agree that reproductive health is an important area for the development of clinical guidelines. NICE has identified women’s and reproductive health as a priority area for guideline development, and already has an extensive portfolio …
Partially Accepted
#35 — Strengthen annual GP appraisal with performance indicator on women's reproductive health diagnosis and treatment.
Recommendation: The annual GP appraisal process should be strengthened to include a specific performance indicator on the diagnosis and treatment of women’s reproductive health conditions, including intersectional considerations. That indicator should include patient experience.
Gov response: Primary care is often the first point of contact for women seeking help with their reproductive health and so it’s vital that GPs are well supported to care for reproductive health conditions. Doctors must regularly …
Not Accepted
#9 — Summarise findings and outcomes of MOD complaints policy review in report response.
Recommendation: We understand that MOD were conducting a review of the complaints policy and process, and of the quality of contractors’ responses to complaints to improve the customer experience. We trust that work on this review is now complete and ask …
Gov response: The MOD agrees with the conclusion and accepts recommendations 8 and 9 which is critical for enhancing the customer experience for Service Personnel and their families. In this context, the role and responsibilities of Housing …
Under Consideration
#8 — Ensure Pinnacle's housing officers effectively resolve issues and complaints with partners.
Recommendation: If the housing officer role is to continue being undertaken by Pinnacle, then Pinnacle’s representatives must be more effective at resolving outstanding issues and complaints, working collaboratively with their contract partners. (Conclusion, Paragraph 59)
Gov response: The MOD agrees with the conclusion and accepts recommendations 8 and 9 which is critical for enhancing the customer experience for Service Personnel and their families. In this context, the role and responsibilities of Housing …
Under Consideration
#5 — MOD's performance recovery claims demand demonstrable improvement in customer experience and trust.
Recommendation: The MOD’s claims of a recovery in performance need to be borne out in a demonstrable improvement in the customer experience and markedly increased customer satisfaction. Service families’ trust has been affected and the DIO and service providers need to …
Gov response: The MOD accepts the recommendation and agrees with the conclusion set out in 4 and 5. The DIO is working closely with its IPs, Families Federations and Service Personnel and their families to identify performance …
Under Consideration
#4 — Outline assurance processes and review performance measures for service families' satisfaction.
Recommendation: The DIO and its contractors should outline the assurance processes they have in place to ensure maintenance and repairs meet the needs of service families. The DIO should also review the performance measures in the RAMS and NAMS contracts to …
Gov response: The MOD accepts the recommendation and agrees with the conclusion set out in 4 and 5. The DIO is working closely with its IPs, Families Federations and Service Personnel and their families to identify performance …
Under Consideration
#38 — Lack of clear standards for supported housing licensing schemes risks inconsistency.
Recommendation: We suggested that the licensing schemes that local authorities were considering would turn out to be very different from each other, unless there was a clear standard to be followed. We were concerned about evidence that, in the absence of …
Gov response: 7.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2026 7.2 A consultation on the implementation of measures in the Supported Housing (Regulatory Oversight) Act was published on 20 February 2025 and …
Accepted
#37 — MHCLG to consult on supported housing regulations and licensing scheme in early 2025.
Recommendation: We asked MHCLG what progress it had made in implementing the Act. It replied that it would issue a consultation on the regulations and a licensing scheme for supported housing landlords early in 2025. It would seek to make the …
Gov response: 7.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2026 7.2 A consultation on the implementation of measures in the Supported Housing (Regulatory Oversight) Act was published on 20 February 2025 and …
Accepted
#7 — Implement the provisions of the Supported Housing (Regulatory Oversight) Act as quickly as possible.
Recommendation: Despite legislation designed to tackle well-established problems and gaps in regulation, MHCLG has made no progress in improving the oversight of the supported housing sector. Supported housing can provide much-needed homes for people transitioning from homelessness, or may stop people …
Gov response: The government agrees with the Committee’s recommendation. (Regulatory Oversight) Act was published on 20 February 2025 and is open for 12 weeks. This sets out proposals on a locally led licensing regime for supported housing …
Accepted
#29 — Review roles of transport accessibility enforcement bodies and legislate for consistent, sufficient powers.
Recommendation: The Department should within 12 months review the roles of enforcement bodies with responsibilities for transport accessibility and prepare to legislate where necessary: • to ensure that all have consistent and sufficient powers at their disposal, and have both the …
Gov response: 31. The Department agrees that there should be no ambiguity about the importance of all relevant parties fulfilling their duties on accessibility. The Department sets the policy framework for transport accessibility, which regulators enforce. As …
Not Addressed
#28 — Mandate regulators with resources to proactively enforce accessibility laws and publish breach data.
Recommendation: The Secretary of State should immediately give regulators an explicit mandate, backed by the necessary resources, to be far more proactive within the scope of their current powers in identifying and enforcing against breaches of accessibility law and regulations by …
Gov response: 31. The Department agrees that there should be no ambiguity about the importance of all relevant parties fulfilling their duties on accessibility. The Department sets the policy framework for transport accessibility, which regulators enforce. As …
Not Addressed
#27 — Effective enforcement routes for street environment accessibility are absent and insufficient.
Recommendation: There appears to be no effective or easily available enforcement route for accessibility in the street environment in particular. There is instead a reliance on upstream measures such as local authorities following good practice, consulting effectively and having “due regard” …
Gov response: 31. The Department agrees that there should be no ambiguity about the importance of all relevant parties fulfilling their duties on accessibility. The Department sets the policy framework for transport accessibility, which regulators enforce. As …
Not Addressed
CQC inspection actions(467)— showing 50 strongest matches
Cygnet Bury Hudson
The provider must ensure that systems and processes operate effectively to assess, monitor and improve the quality and safety of the services provided:
Must Do
Cotton Exchange
The provider must have systems and processes such as regular audits of the service and must assess, monitor and improve the quality and safety of the service.
Must Do
Cottesmore House
Systems or processes were not established and operated effectively to ensure compliance with the requirements in this Part.
Must Do
Continuity Healthcare Services Private Limited
The provider had not ensured that systems or processes operated effectively to assess, monitor and improve the quality of the service and mitigate the risks relating to the health, safety and welfare of service users. The provider had not maintained …
Must Do
Clare House Residential Home
The provider failed to ensure that their systems and processes were effective in monitoring the quality and safety of the services being provided.
Must Do
Chatham House
The provider must have effective systems in place to regularly assess, monitor and improve the quality of the service and act on feedback provided by people using the service.
Must Do
Chandos Lodge Nursing Home
The provider did not ensure their quality assurance processes were effective. Regulatory requirements were not always understood.
Must Do
Brook House Residential Home
Improve quality monitoring systems to identify and address areas requiring improvement, including gaps in decision-making processes, medicine administration timings, and environmental challenges.
Must Do
Billet Lane Medical Practice
Establisheffectivesystemsandprocessestoensuregoodgovernanceinaccordancewiththefundamentalstandards ofcareandtreatment.
Must Do
Baby Bump Limited
The service must have effective governance systems or processes to ensure the safe and effective delivery of care. Systems and processes must be regularly audited.
Must Do
Assured Care Formby
Governance processes were knot established or operated effectively.
Must Do
Agnes House 81
Quality monitoring systems were not robust. There was a lack of evidence that the provider was continually evaluating the service and making the required improvements.
Must Do
Aaron Abbey Care Services Limited
The registered person must ensure that systems or processes are established and operated effectively to ensure compliance with the requirements of regulations 8 to 20A of the HSCA 2008 (Regulated Activities) regulations 2014.
Must Do
Woodlands
Regulation 17 HSCA RA Regulations 2014 Good governance
Must Do
Winterton House
Systems or processes were not established and operated effectively. Systems or processes did not enable the registered person to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity. The …
Must Do
Victoriana Care Home
There was a lack of effective systems to ensure quality safe care was always provided.
Must Do
Verve Health
The service must ensure governance systems and processes are in place to assess, monitor and improve the quality and safety of the service.
Must Do
Valewood House Nursing Home
People were not protected against the risks of inappropriate or unsafe care and treatment by means of the effective operation of systems designed to regularly assess and monitor the quality of the services provided and to identify assess and manager …
Must Do
Universal Care - Beaconsfield
The provider failed to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services). The provider failed …
Must Do
Taplow Manor
The service must ensure that there are effective and robust governance procedures in place to ensure that young people always receives safe care and treatment.
Must Do
Southwinds
The provider did not have effective systems in place to assess, monitor and improve the quality and safety of the service.
Must Do
Serenity House
There was a lack of effective systems and processes in place for monitoring quality of the service.
Must Do
Reside at Southwood
The provider must ensure that effective systems and processes are established to assess, monitor and drive improvement in the quality and safety of services provided and that accurate records are maintained.
Must Do
Nower House
The failure to ensure consistent management oversight of the service and respond to shortfalls in a timely manner was a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Nicholas House
The culture of the service did not promote high-quality care and support. Quality assurance systems were not robust enough to demonstrate the service was effectively managed.
Must Do
Laurel Lodge Care Home
The provider must ensure that effective governance systems are established and operated to monitor the quality of the service, identify risks to the health and safety of people, and drive continuous improvement.
Must Do
Kingsleigh Residential
The provider failed to operate effective systems to monitor the safety and quality of the service.
Must Do
Highfield House Residential Home
The provider must ensure good governance.
Must Do
Havilah Office
Systems or processes were not established and operated effectively to assess, monitor and improve the quality and safety of the services provided. Regulation 17 (1) (2) (a)(b)(c)
Must Do
Haisthorpe House
The provider must ensure people who used services are protected against the risks of inappropriate or unsafe care and treatment, by means of the effective operation of systems designed to enable the registered person to regularly assess and monitor the …
Must Do
Gledhow Lodge
Quality assurance processes were not robust or effective in identifying areas of improvement and analysing records for trends and themes. Records were not always managed effectively.
Must Do
Dr French Memorial Home Limited
Systems were either not in place or robust enough to demonstrate that the services were of good quality and safety was effectively managed. Reg 17 (1)
Must Do
Chiltern View
The provider must ensure quality monitoring systems are used to identify and address shortfalls in the quality of the service, and that management oversight is effective.
Must Do
Cedar House
Management oversight processes in place failed to establish and operate systems to ensure compliance, assess, monitor and improve the quality and safety of the service.
Must Do
Cary Lodge
Systems and processes had failed to adequately assess, monitor and improve the quality and safety of people. Records were not always accurate. 17(1)(2)(a)(b)(c)
Must Do
Brushwood
The provider's governance and quality assurance systems were not always effective.
Must Do
Benthorn Lodge
The registered person did not have an effective system in place to monitor the quality of care provided to people or to manage risks of unsafe or inappropriate treatment. There was a lack of management and leadership at the service.
Must Do
Benedict House Nursing Home
The provider put in place effective systems to monitor the quality and safety of the service that people receive.
Should Do
Ashcroft House - Leeds
The provider had not ensured systems and processes operated effectively to assess, monitor and mitigate the risks relating to the health, safety and welfare of people and to improve the quality and safety of the service provided.
Must Do
Arthur House
The provider did not have robust, consistent and adequate systems in place to monitor the quality of the service.
Must Do
Archers Point Residential Home
There were not effective systems in place to assess and monitor the quality of the service provided.
Must Do
Yanah Care
The provider must ensure effective systems and processes are in place to assess, monitor and improve the quality and safety of the services provided to people.
Must Do
Woodview House Nursing Home
Systems and processes to ensure monitoring and oversight of the quality and safety of the service were not operating effectively.
Must Do
Woodbridge Lodge Residential Home
The governance systems in place were not robust enough to identify shortfalls and address them.
Must Do
Wishingwell Residential Care Home
The provider had not established and operated effectively systems and processes to assess, monitor and improve the quality and safety of the service and to mitigate risks. Regulation 17(1).
Must Do
Willow Court
The lack of robust quality assurance meant people were at risk of receiving poor quality care.
Must Do
Widnes Hall
The provider must operate effective systems to ensure the safety and quality of the service.
Must Do
Westwood Care Home
The provider had failed to ensure governance systems were effective in monitoring service quality, responding to poor quality and driving improvement.
Must Do
Westacre Nursing Home
We found no evidence that people had been harmed however, there was a failure to operate effective systems to assess, monitor and improve the service.
Must Do
West Farm House
Shortfalls in the service were not being identified and addressed.
Must Do
ICIBI immigration recommendations(8)
An inspection of illegal working enforcement (August – October 2023)
In relation to assurance: (a) as a matter of priority, re-introduce a formal first-line assurance process. (b) ensure that second-line assurance covers all operational areas, including planning activity. (c) review …
An inspection of asylum casework (August 2020 – May 2021)
Ensure all first line quality assurance takes place before asylum decisions are served. Ensure that trends in Second Pair of Eyes (SPoE) feedback are identified and analysed, and that the …
An inspection of asylum casework (June - October 2023)
Ensure all first line quality assurance takes place before asylum decisions are served. Ensure that trends in Second Pair of Eyes (SPoE) feedback are identified and analysed, and that the …
An inspection of asylum casework (August 2020 – May 2021)
Introduce Calibre assurance assessments for screening interviews
A further inspection of the EU Settlement Scheme July 2020 – March …
Recommendation 5 Review the robustness of the quality assurance regimes in place for EU Settlement Scheme (EUSS) caseworkers and Settlement Resolution Centre (SRC) staff, in the process explaining to staff …
An inspection of visit visa operations December 2022 to January 2023
Improve the existing first-line assurance regime to cover all operational grades and processes, with a focus on routing and decision quality
An inspection of asylum casework (June - October 2023)
Introduce Calibre assurance assessments for screening interviews
An inspection of Border Force practice and procedures in relation to firearms …
Review the current Border Force Assurance Expectations, to ensure that all risks in relation to firearms identification, handling, storage, and transport are subject to adequate first and second-line assurance.
PPO death in custody recommendations(6)
Manx Care
Manx Care should have a dedicated clinical governance lead responsible for prison healthcare at Isle of Man Prison to ensure practice is compliant and underpinned by national guidance, legislation and evidence-based practice.
The Chief Executive of NHS Wales
The Chief Executive of NHS Wales should ensure that prison dental surgeries in Wales are subjected to the same level of scrutiny and inspection as community dental surgeries.
The Governor
The Governor should review whether the quality assurance process for escort risk assessments is sufficiently robust and consider introducing SLT review of a random sample to identify any ongoing issues.
The HMPPS Executive Director for Custodial Contracts
The HMPPS Executive Director for Custodial Contracts should write to the Ombudsman setting out what he has done to satisfy himself that healthcare services at Rye Hill, including the contract for GP services, meet the needs of the prison’s population.
The Director
a robust quality assurance process is implemented to check that these measures are in place and effective.
The Governor
The Governor should review the quality and compliance with policy of ACCT management in the previous 12 months, identify any improvements required, and devise a plan to deliver those improvements.
IOPC learning recommendations(16)
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should take steps to ensure there is effective supervision and quality assurance in place for officers where there is little measurable work output to review, to ensure the maintenance of policing standards and officers’ …
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should assure itself that sufficient steps have been taken to ensure appropriate supervision and welfare is in place to prevent officers becoming isolated through their duties. This follows an investigation into allegations of misconduct …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that Northumbria Police should continue to adhere to their dip sampling policy of domestic violence cases in order to identify any improvement opportunities and put in place a clear and robust and documented plan for remedial action …
Care and attention for man whilst detained in custody – Thames Valley …
The IOPC recommends that Thames Valley Police ensures that the quality of the cell checks conducted by detention officers are regularly monitored by their supervisors, and any concerns are recorded and fed back to them. This follows an investigation into …
Recommendations - National Police Chiefs' Council, December 2024
The IOPC recommends that the National Police Chiefs’ Council (NPCC) should review the processes through which the Flexible Lift and Carry System (FLACS) and other operational equipment are introduced and reviewed and ensure these are aligned with the most recent …
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should take appropriate steps to assure itself that the bullying and harassment identified through Operation Hotton is not more widely prevalent across the MPS. This follows an investigation into allegations of bullying and harassment …
Police investigation into how a child sustained injuries – Cleveland Police, February …
The IOPC recommends that Cleveland Police should review the systems in place for supervisory entries onto Occurrence Enquiry Logs (OEL’s) to ensure that in future criminal investigation cases it is not possible for one person to be both the Officer …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that that when closing domestic violence cases Northumbria Police should put in place a system of supervisory oversight in line with the HMICFRS VAWG Report Recommendation update dated 13 June 2023. This will allow supervisory oversight and …
Failure to investigate indecent exposure – Metropolitan Police Service, February 2021
The IOPC recommends that the Metropolitan Police Service (MPS) considers the development of a system which automatically notifies the Directorate of Professional Standards (DPS) of when a serving police officer is linked to an ongoing police investigation. This follows an …
Recommendations - National Police Chiefs' Council, December 2024
The IOPC recommends that the National Police Chiefs’ Council (NPCC) requires all forces to ensure they have mechanisms for recording the use of Flexible Lift and Carry Systems (FLACS), and similar manual handling devices, thereby providing a clear auditable process …
Recommendations - National Police Chiefs' Council, December 2024
The IOPC recommends that the National Police Chiefs’ Council (NPCC) should undertake medical testing of the Flexible Lift and Carry System (FLACS) independent of the manufacturer. This should include testing of whether the FLACS can be safely used after a …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that Northumbria Police should remind staff of their responsibility to identify and respond appropriately to vulnerable victims and that supervision of incidents concerning vulnerable victims is robust and effective and that all available evidence/intelligence is imputed onto …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that Northumbria Police review training for Call Centre staff with regard to risk grading and that domestic violence incidents graded 1 or 2 receive a prompt response. This should be done by continuous dip sampling to check …
Investigation into police pursuit and subsequent road traffic incident - Metropolitan Police …
The IOPC recommends the Metropolitan Police Service establish if car radios fitted in police response vehicle are fit for purpose, are in full working order and the audio function works appropriately. They should also reinforce to officers the necessity to …
Investigation into recruitment irregularities and the actions of a civilian staff member …
The IOPC recommends that British Transport Police reviews the current practice of passing investigations between different teams within the Professional Standards Department and different appropriate authority delegates and sets out clear roles and responsibilities for all those involved in carrying …
Investigation into recruitment irregularities and the actions of a civilian staff member …
The IOPC recommends that British Transport Police considers working practices in the Professional Standards Department to consider and take action to address any issues with: During our investigation we found that there were various issues with the processes followed in …
NAO audit recommendations(16)
NHSE's management of elective care transformation programmes
NHSE plans to reset its central oversight arrangements for elective recovery. As it establishes its new national level oversight board for the transformation programmes it should: ? ensure that performance information reported to the board is prioritised, clear and consistent …
Accepted
Financial sustainability of colleges in England
d) Evaluate, and take action to improve, the effectiveness of the early and formal intervention regimes in improving colleges’ financial sustainability. At a time of significant funding and cost pressures, intervening successfully is particularly challenging. However, it is important for …
Accepted
Resilience to animal disease
b support APHA to improve its systems and processes in ways that will ensure more efficient and effective responses to outbreaks; this could include providing ongoing support for APHA?s Delivering Sustainable Future programme;
Accepted
NHSE's management of elective care transformation programmes
NHSE should do more to secure buy-in from clinicians across its programmes. It should achieve this by: ? continuing to build support and endorsement nationally by strengthening its work with Royal Colleges and through national clinical directors embedded in the …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 5: NHSE should revisit internal quality assurance arrangements for existing models when they are used for a new purpose, such as the models used to provide input data for the workforce modelling, and ensure independent scrutiny is evidenced accordingly.
Accepted
Progress in improving mental health services in England
e) As mental health services will need to remain the focus of sustained improvement and in the light of national and local reorganisation of health bodies, DHSC and NHSE should set out the future approach to leading, monitoring and assuring …
Accepted
Progress in improving mental health services in England
c) NHSE, working with local ICBs and providers, should improve its data and analysis to better understand the relative cost and cost-effectiveness of different services, and provide a more robust basis to decide future priorities.
Accepted
Introducing Integrated Care Systems: joining up local services to improve health outcomes
d) by April 2023, NHSE should fully align its oversight of ICBs with the strategic objectives for ICSs. Specifically, it should: ? agree with ICBs what they can realistically deliver against each of the four purposes, taking account of individual …
Accepted
NHS financial management and sustainability
NHSE&I should put in place a regulatory and oversight system that aligns with the responsibilities placed upon individual NHS bodies and their role within non-statutory sustainability and transformation partnerships and integrated care systems. This should clearly set out how roles …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 7: Modelling of this kind requires gathering assumptions about the future of the NHS in one place. This presents an opportunity to expose those assumptions widely to scrutiny and challenge, both internally and externally. Assumptions should be generated in …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 4: NHSE should ensure quality assurance practices take place in a timely manner, so analysts have sufficient time to respond accordingly.
Accepted
Progress in improving mental health services in England
d) NHSE, working with ICBs, should develop and issue guidance in 2023 on how the system will gain more transparency over capacity, activity, performance and outcomes in community mental health services, including improvements required to implement the proposed new clinical …
Accepted
Government Shared Services
f) Departments working together as clusters should complete individual ?declarations? that set out agreed ways of working and reaffirm their commitment to the Shared Services Strategy. This should be signed by each departmental accounting officer.
Accepted
Government Shared Services
c) The Cabinet Office should streamline its central governance arrangements so that they avoid duplication and unnecessary work for departments.
Accepted
Government Shared Services
e) Departments should establish cluster-level governance arrangements to avoid duplication in decision-making and to embed the cluster model. It should no longer use existing departmental governance routes to approve high-level strategy decisions.
Accepted
Introducing Integrated Care Systems: joining up local services to improve health outcomes
e) NHSE should evaluate whether it can draw lessons from the simplified system of commissioning and contracting arrangements put in place for the NHS during 2020-21 and 2021-22, and streamline the requests made to front-line providers while retaining the information …
Accepted
PHSO ombudsman recommendations(5)
Ignoring the alarms: How NHS eating disorder services are failing patients
Both NHS Improvement and NHS England have a leadership role to play in supporting local NHS providers and CCGs to conduct and learn from serious incident investigations, including those that are complex and cross organisational boundaries.
Ignoring the alarms: How NHS eating disorder services are failing patients
NICE should consider including coordination as an element of their new Quality Standard for Eating Disorders.
Broken trust: making patient safety more than just a promise
The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families.
Broken trust: making patient safety more than just a promise
As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses them. This should include where local …
Broken trust: making patient safety more than just a promise
Integrated care boards, with oversight from NHS England, should closely monitor the impact of the PSIRF to identify any negative consequences of the new flexibility it offers, which gives Trusts more autonomy to decide when a patient safety investigation is …
IMB annual reports(2)
Hull (2021)
During the reporting year dominated by COVID-19, HMP Hull remained a safe prison with reduced violence and aggression, despite two self-inflicted deaths. Staff and prisoners collaborated well, and new communication and education methods supported coping. However, pandemic restrictions severely limited prisoners' time out of cells to approximately one hour daily, highlighting issues with shared Victorian cells. While healthcare provision was maintained under pressure, the Board raised concerns about the management oversight of the external provider (CHCP) and the complexity of the complaints system.
PRISON
Key concerns
Exeter (2022)
HMP Exeter, a Category B local and resettlement prison, experienced persistent high levels of violence and self-harm, alongside challenges with staffing instability and extensive refurbishment work in 2022. While healthcare provision was generally satisfactory, access to psychological therapies remained limited, and living conditions were often impacted by overcrowding and restricted regimes. Progress towards successful resettlement was hindered by short sentences, lack of work opportunities, and staff shortages.
PRISON
Key concerns
IMB individual recommendations(8)
Winchester (2024)
What can be done to further hold to account Practice Plus Group's activities for the purposes of monitoring delivery of healthcare services under terms of contract and PSO1700?
HMPPS
In Progress
Elmley (2024)
Address the inconsistency in the quality of ACCT documents through effective quality assurance.
Governor / Director
Humber (2023)
The Board acknowledges the 12 key concerns identified by HMIP in its recent report and agrees they should be progressed during the coming reporting year, subject to the necessary resources being available. The Board will endeavour to structure its monitoring to reflect these concerns and the progress made in addressing them.
Governor / Director
Thorn Cross (2024)
To provide the Board with regular and timely evaluation of all aspects of the prison’s performance.
Governor / Director
Leicester (2022)
The Board would like to draw the minister’s attention to its continued concerns about the service provided (5.1.2).
Ministry of Justice
Gartree (2022)
Therefore, can the Minister confirm to the Board that all services being provided to Gartree by outside organisations (e.g. healthcare, maintenance and education) are achieving all quality and performance targets for the services they have been commissioned to provide?
Ministry of Justice
Hollesley Bay (2024)
The Board is pleased to acknowledge the very positive result of the unannounced HMIP inspection in April. It also notes the positive comments by the Chief Inspector.
Governor / Director
Noted
Wakefield (2022)
We ask the minister and his/her officials to explain how the ministry perceives the performance of prisoner healthcare at HMP Wakefield when compared against the performance specification in the contract.
Ministry of Justice
Noted
Health investigations(6)
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1c
Urgent prioritisation of the national Beacon dashboard, with routine use embedded to support whole system learning and improvement, and regular public reporting. A real-time safety signals dashboard, overseen by a clinically and academically informed subgroup of the national oversight group to enable early identification of risk and timely intervention.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1b
A National Strategic Oversight Board should include all relevant national stakeholders with responsibility for perinatal services, the national perinatal team, and a service user representative, with the aim of providing comprehensive oversight and shared accountability. The Board should meet regularly to provide a single, coordinated mechanism for monitoring and acting …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1a
The appointment of national Clinical Directors or leads in obstetrics, neonatology, neonatal nursing and obstetric anaesthetics. These roles should form a National Perinatal Team, working alongside the Chief Midwifery Officer to advise the Welsh Government, drive policy development and implementation, and provide strengthened clinical oversight and accountability of Health Boards …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1d
A comprehensive, accessible governance map, accompanied by a clear narrative explanation of roles, responsibilities, decision-making routes and escalation pathways, should be developed and published within six months of the publication of this report.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1bii
The assurance assessment panel has benefited significantly from advice and challenge provided by a wider stakeholder group. We recommend this group is formally retained, meeting quarterly with clear terms of reference to inform the national strategic oversight Board, and that its membership is expanded to include educators, researchers and student …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1bi
We recommend that the planned National Maternity and Neonatal Voices Panel also includes representatives from community advocacy organisations representing populations at increased risk of poorer experiences and outcomes in perinatal services, and that it elects a representative to sit on the national strategic oversight Board.
wales
Accepted
Detention investigations(12)
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
Assessment of government progress in implementing the report on the … — Rec 42
The Home Offce should strengthen its own assurance processes to examine adherence to professional standards and staff culture in IRCs on a regular basis.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 46
I recommend that IND gives urgent consideration to contract monitoring in relation to all holding rooms.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 43
The computerised monitoring schedule needs to be redesigned to make it more flexible and adaptable in monitoring and recording non-commercial aspects of the contract; A training analysis should be conducted across monitoring teams to ascertain the levels of understanding surrounding issues of passive discrimination. The above recommendations should be applied …
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 42
I recommend that IND and the National Council of IMBs take steps to provide IMB scrutiny of all areas (that is, vans and holding areas) where detainees are held.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 40
I recommend that the IMB carry out more frequent, unannounced visits between 9:00pm and 9:00am in order to assess the centre during all its hours of operation.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 50
I also recommend that the performance of the RFU – in terms both of facilitating removals and forestalling problems between the contractor and the detainee – is monitored with a view to introducing a RFU at other ports.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 47
I recommend that IND considers the advantages and practicality of contract monitors carrying out investigations into allegations against staff in other centres.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R10
The SMT should undertake unannounced observation of training sessions as part of the evaluation and quality assurance of training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R9
The SMT and G4S managers should undertake regular and systematic evaluation and quality assurance of the training provided at Gatwick IRCs to ensure that staff receive training of a consistently high standard; that it meets the operational needs of the IRCs, trains and develops staff appropriately and promotes appropriate values. …
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 47
IND reviews and clarifies its role in overseeing the operation of removal centres, notwithstanding principles pertaining to transfer of risk.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 39
I recommend that Oakington’s IMB members be offered refresher training in relation to their powers and how to ensure maximum effectiveness.
Immigration Detention
PHSO casework decisions(8)
P-003058 — Care Quality Commission
Mr and Mrs B complain the Care Quality Commission failed to properly inspect the Nursing Home. The also say It failed to act on intelligence it received about the Nursing Home before the inspection and it did not take account of relevant evidence during the inspection. They also complain about …
UK Government
Partly Upheld
Oct 2024
P-003045 — Care Quality Commission
Dr C explains that after the coroner’s inquest concluded, more information came to light and she raised concerns with the CQC about her foster son’s care. She complains it has not correctly addressed the issues she raised or taken any enforcement action.
UK Government
Upheld
Aug 2024
P-003539 — Care Quality Commission
Mrs O says the CQC failed to act against her daughter’s college. She complains it failed to take appropriate action after inspections in January and February 2023 and to prosecute the college after she gave it evidence in 2023 and 2024.
UK Government
May 2025
P-003487 — Care Quality Commission
Mrs X complains on behalf of staff at the hospice, about the attitude and behaviour of a CQC Inspector, during an inspection.
UK Government
Apr 2025
P-004114 — Care Quality Commission
Miss A is unhappy with the CQC's handling of her applications to register her new health business. In addition she complains about complaint handling.
UK Government
Sep 2025
P-003503 — Hertfordshire and West Essex Integrated Care Board
Ms K complains Hertfordshire and West Essex Integrated Care Board did not oversee and respond appropriately to the concerns she raised in September 2022 about the care being provided to her father whilst resident in a care home.
NHS in England
Apr 2025
P-003511 — NHS England
Dr R complains that NHSE independent review panel (IRP) upheld the ICB’s decision that his mother was not eligible for NHS CHC when it assessed her care needs on 10 May 2022.
NHS in England
Apr 2025
P-003683 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Miss A complains York & Scarborough Teaching Hospitals Trust failed to investigate suspicious findings when Mrs C underwent a hysterectomy.
NHS in England
Partly Upheld
Jul 2025
LGO / SPSO decisions(35)
201400244 — Care Inspectorate
Ms C owns a childcare business. She initially set the business up with her daughter (Miss A) and registered the partnership with the Care Inspectorate. Miss A subsequently left the business and Ms C's son (Mr A) joined as her partner. This partnership change came to light during a routine …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Partly Upheld
Dec 2015
201202561 — Care Inspectorate
Miss C's mother had received care services through her local council for a number of years, but these were suddenly withdrawn. Miss C complained to the council and also asked the Care Inspectorate to investigate. The Care Inspectorate investigated four complaints about the council's termination of Miss C's mother's care …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Partly Upheld
Sep 2013
25-004-224 — Danforth Care No. 1 Limited
Summary: Ms X complained about poor service during her respite stay at Heatherton House, and the care provider’s failure to escalate her concerns. She left early due to the undue distress caused. Ms X received a partial refund for the unused days since making the complaint to us. The evidence …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
PSOW-202103154 — Meddyg Care Porthmadog
Mr A, through his Community Health Council Advocate, complained about the care and treatment his father, Mr B, received at the Care Home. Mr B’s care needs meant he was in receipt of NHS Continuing Health Care (“NHSCHC”) from the Health Board who were responsible for monitoring the care provided …
PSOW (Public Services Om…
Health
Upheld
Feb 2023
PSOW-202408904 — Welsh Government - Care Inspectorate Wales
Ms C complained that Care Inspectorate Wales had not acted impartially when it investigated and responded to her complaint. The Ombudsman decided that the Body’s investigation did not lack impartiality, but the response had not fully considered that there had been a breakdown in communication regarding the availability of training, …
PSOW (Public Services Om…
Mar 2025
21-009-703 — London Residential Healthcare Limited
Summary: The Care Provider acknowledged the care provided to Mrs Y was below an acceptable standard before the involvement of this office, but it did not offer an appropriate remedy for the injustice caused.
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
24-019-026 — The Fremantle Trust
Summary: We will not investigate this complaint about the quality of care provided in a care home. This is because any injustice is insufficient to justify our involvement.
LGO (Local Government & …
Adult Care Services
Apr 2025
24-015-590 — North East Lincolnshire Council
Summary: We will not investigate this complaint about the quality of domiciliary care. The Council has refunded the cost of Mrs Y’s care and apologised to her daughter, Mrs X. Further investigation by us is unlikely to achieve anything more meaningful.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2025
202106302 — East Dunbartonshire Health and Social Care Partnership
C complained about the care provided to their elderly parent (A). A had to remain in bed to allow several pressure sores to be treated. To assist with moving A out of bed and changing A's position, a manual handling assessment was requested. C felt that there was an unreasonable …
SPSO (Scottish Public Se…
Health and Social Care
Upheld
Aug 2023
PSOW-202200031 — Plas Gwyn Nursing Home
Mrs X complained that she was unable to visit the Care Provider and had not received a response to her complaint. The Ombudsman was concerned that Mrs X had yet to receive a response to her concerns and contacted the Care Provider. As an alternative to an investigation, the Care …
PSOW (Public Services Om…
Health
Apr 2022
PSOW-202102997 — Betsi Cadwaladr University Health Board
Mr A, through his Community Health Council Advocate, complained about the care and treatment his father, Mr B, received at the Care Home. Mr B’s care needs meant he was in receipt of NHS Continuing Health Care (“NHSCHC”) from the Health Board who were responsible for monitoring the care provided …
PSOW (Public Services Om…
Health
Upheld
Feb 2023
22-008-440 — Jubilee Court Care Ltd
Summary: We will not investigate this complaint about adult social care provision because the injustice claimed is not serious enough to warrant our involvement and the use of public money.
LGO (Local Government & …
Adult Care Services
Oct 2022
23-011-659 — Barchester Healthcare Homes Limited
Summary: Mrs X complains, on behalf of her father, Mr Y, Barchester Healthcare Homes Limited mishandled the pre-admission process and failed to ask relevant questions before her father moved into in the home. She says the Care Provider failed to engage with her or social services to complete a re-assessment. …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2024
201508742 — Care Inspectorate
Mr C complained to us that the Care Inspectorate had published an inspection report on his nursery that was inaccurate. He stated that there were a large number of errors in both the draft report and the final published report. We found that although there had been errors in the …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Not Upheld
May 2017
25-011-335 — Care UK Care Services Limited
Summary: We will not investigate Ms X’s complaint about the residential care provided to her mother Ms Y.
LGO (Local Government & …
Adult Care Services
Jan 2026
24-023-387 — Sheffield City Council
Summary: I find fault in the care provided by a care provider acting on behalf of the Council. The Council has agreed to provide a remedy.
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
25-010-204 — Green Lane Care Centre
Summary: We cannot investigate this complaint as it is outside our jurisdiction. Mr X’s care was arranged and funded by the NHS and so the complaint can be investigated by the Health Services Ombudsman.
LGO (Local Government & …
Adult Care Services
Jan 2026
PSOW-202205658 — Cwm Taf Morgannwg University Health Board
Mr E complained about Cwm Taf Morgannwg University Health Board’s handling of his complaint about the care provided to his mother. The Ombudsman decided that the Health Board had failed to provide regular and meaningful updates and had not issued a complaint response to Mr E. She said that this …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202206173 — Cwm Taf Morgannwg University Health Board
Ms D complained that Cwm Taf Morgannwg University Health Board had failed to provide a complaint response to correspondence she sent to it in February 2022. The Ombudsman found that the Health Board had acknowledged Ms D’s letter but had failed to respond to it. She said that this caused …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202206233 — Betsi Cadwaladr University Health Board
Mrs A complained that the Health Board had failed to issue a complaint response to her in accordance with an agreement it had previously reached with the Ombudsman’s office (ref: 202204472). The complaint response should have been issued to Mrs A by 30 November 2022. The Ombudsman contacted the Health …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202105999 — Cwm Taf Morgannwg University Health Board
Miss A’s complaint related to the care and treatment that she received during her admission to Prince Charles Hospital in April 2021. Specifically, Miss A complained that she was inappropriately discharged on 22 April as she was not properly examined, such as with a speculum or an ultrasound, following the …
PSOW (Public Services Om…
Health
Not Upheld
Dec 2022
PSOW-202108104 — Swansea Bay University Health Board
Mr A’s complaint centred on his care and management at Morriston Hospital (“the Hospital”). He complained that the Swansea Bay University Health Board (“the Health Board”) failed to accurately diagnose giant cell arteritis (“GCA” – inflammation in the lining of the arteries especially in the temple) and provide timely treatment …
PSOW (Public Services Om…
Health
Upheld
Feb 2023
PSOW-202206156 — Cardiff and Vale University Health Board
Mr C complained that Cardiff and Vale University Health Board had failed to adequately address his concerns about the care and treatment provided to his late father. The Ombudsman found that whilst the Health Board had issued a complaint response it had delayed making further contact with Mr C about …
PSOW (Public Services Om…
Health
Feb 2023
PSOW-202402334 — Estyn
Mr W complained about whether Estyn’s investigation into his complaint at Stage 2 of its complaints procedure was completed reasonably and in accordance with its ‘Complaint Handling Procedure 2021’. The Ombudsman found that Mr W’s complaint was not investigated in accordance with Estyn’s Complaint Handling Procedure 2021 which states that …
PSOW (Public Services Om…
Upheld
Jun 2025
22-002-226 — Liberty House Clinic Limited
Summary: We will not investigate this complaint about a Private Care Provider. This is because there is insufficient injustice caused to warrant our intervention. Also, some actions complained of fall outside of our jurisdiction as they do not relate to the provision of adult social care.
LGO (Local Government & …
Adult Care Services
Jun 2022
22-003-864 — Sunderland City Council
Summary: We will not investigate this complaint about the standard of care Mrs Y received in a nursing home. That is because further investigation would not lead to a different outcome.
LGO (Local Government & …
Adult Care Services
Jul 2022
23-014-133a — Maria Mallaband Care Group Ltd (23 014 133a)
Summary: Mrs X complained about the treatment and care provided to her late grandmother, Mrs Y while she was living in a nursing home. We will not investigate Mrs X’s complaint because it is unlikely we could add to the responses she has already received from the organisations she complains …
LGO (Local Government & …
Health
May 2024
23-014-029 — Yourlife Management Services Limited
Summary: Ms X complains YourLife (Droitwich) failed to meet her father’s (Mr Y’s) needs when he went to live in Horton Mill Court in July 2021 and told his family he had to leave, resulting in him having to live in a care home and incurring losses selling his flat. …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
201103809 — Tayside NHS Board
Mr C complained that the board did not provide pelvic support girdles, which he considered his partner needed because of pelvic pain in pregnancy. We explained to him that our role in such complaints is limited because it is not for us to tell the NHS how to use their …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2012
201102661 — A Medical Practice in the Fife NHS Board …
Mr C complained that his GP practice decided to restrict the number of diabetic testing strips he could have, and then stopped providing them. He said that this was unfair and did not take into consideration his personal circumstances. Mr C said that self monitoring of his diabetes cannot be …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2012
201102066 — Care Inspectorate
Ms C, a childminder, complained about the Care Inspectorate’s decision to uphold a complaint that she did not have a safety net on a trampoline used by the children in her care. She said that this had not been pointed out on previous inspections. The law says that we cannot …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Partly Upheld
Jul 2012
201407618 — Care Inspectorate
Ms C complained to the Care Inspectorate about the care home her father was staying in. She complained about a range of issues, including how often bedding was changed, concerns about electric reclining chairs, and the lack of a care plan for her father. The Care Inspectorate responded to her …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Not Upheld
Aug 2015
PSOW-202308118 — Liberty Care Ltd
Mrs C complained about Aneurin Bevan University Health Board (“the Health Board”) and a registered Residential Care Provider (“the Care Provider”) which the Health Board had commissioned to provide care to her son, Mr A. The investigation looked at whether between November 2021 and October 2022, the Health Board failed …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2025
21-010-477 — Sheffield City Council
Summary: I have ended our investigation into this complaint because the Council has recently begun an independent review of the care provider and service Ms X complained about. Further investigation by us could achieve nothing more.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2022
21-018-997 — Assini Limited
Summary: We cannot investigate this complaint about the actions of a Private Care Provider. This is because the actions complained of fall outside of our jurisdiction to investigate as they do not relate to the provision of adult social care.
LGO (Local Government & …
Adult Care Services
Apr 2022