Staff policy awareness
Absence of a system to confirm that all staff have read and understood existing, updated, or new policies, procedures, and guidance documents.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
IOPC learning recommendation
95match
Police response to an abandoned emergency call – Cleveland Police, March 2020
The IOPC recommends that Cleveland Police policy and guidance documents are relevant and up to date, ensuring standard roles and responsibility policy documents for all supervision and staff working within the control room are in place, fit for purpose and reviewed on a regular basis. If policies/processes change then Cleveland Police should ensure that guidance is updated as...
Matched on
terms: awarenes, policy, staff
Inquiry recommendation
86match
38 - Government department safeguarding policy reviews
The Cabinet Office must ensure that each government department reviews its child safeguarding policy or policies in light of the expert witness report of Professor Thoburn. There must also be published procedures to accompany their policies, in order that staff know how to enact their department's policy. All government departments must update their safeguarding policies and procedures regularly,...
Matched on
terms: policy, staff
PFD report
77match
Seweryn Glowinski
Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies for at-risk prisoners.
Matched on
terms: awarenes, staff
PFD report
77match
Mary Chapman
The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack of evidence that new procedures or multidisciplinary approaches have improved patient safety or consistent practice.
Matched on
terms: policy, staff
Inquiry recommendation
77match
39 - Political party safeguarding policies
All political parties registered with the Electoral Commission in England and in Wales must ensure that they have a comprehensive safeguarding policy. All political parties must also ensure that they have procedures to accompany their policies, in order that politicians, prospective politicians, staff and volunteers know how to enact their party's policy, which must be published online. All...
Matched on
terms: policy, staff
IOPC learning recommendation
77match
Recommendations - West Midlands Police, June 2021
The IOPC recommends that West Midlands Police create a policy on handling concern for welfare calls. This policy should cover the responsibility for informing third parties and should provide guidance for officers and staff members dealing with an enquiry relating to anyone raising concern for the welfare of another person. This recommendation is made following a DSI investigation...
Matched on
terms: policy, staff
PFD report
73match
Rosalind Flett
Ambiguity in the Trust's search policy created a gap between "advanced" and "intimate" searches, preventing staff from conducting thorough searches and potentially missing concealed items.
Matched on
terms: policy, staff
PFD report
73match
Michael Dent-Jones
National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' prescribed medication. Procedures were absent, and staff had not read essential safety documents, indicating broader safety failures.
Matched on
terms: staff
PFD report
73match
Liridon Saliuka
There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.
Matched on
terms: awarenes, staff
IOPC learning recommendation
73match
Recommendations - West Midlands Police, April 2021
The IOPC recommends that West Midlands Police should take steps to formalise the escalation and vulnerability doctrines (as set out in the force document “HMIC Observations and action taken following September 2017 Inspection”) into a compulsory policy and take step to ensure all contact staff are aware of their responsibilities under the policy. If this is formalised into...
Matched on
terms: policy, staff
PFD report
69match
Theresa Robertson
The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient outside policy, with no audit to identify similar systemic breaches in prescription safety.
Matched on
terms: policy
PFD report
69match
Shirley Froggett
New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.
Matched on
terms: staff
PFD report
69match
William Savory
There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff were unaware of the requirement to act immediately. This lack of awareness poses a risk of future delays and deaths.
Matched on
terms: awarenes, staff
PFD report
69match
Cariss Stone
Staff lacked clear understanding of patient observation policy, and ligature cutters were not routinely supplied in a ward with known self-harm risks, posing significant safety concerns.
Matched on
terms: policy, staff
PFD report
69match
Jada Monoja
An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially misleading patient risk assessments, hindering effective management.
Matched on
terms: policy
Detention investigation recommendation
68match
Independent Investigation into Concerns about Brook House Immigration Removal Centre - Rec R47
The SMT should undertake a programme of awareness-raising among staff to improve their understanding and use of the anti-bullying policy. (To be completed within 3 months)
Matched on
terms: awarenes, policy, staff
Inquiry recommendation
66match
55 - Religious organisation child protection policies
All religious organisations should have a child protection policy and supporting procedures, which should include advice and guidance on responding to disclosures of abuse and the needs of victims and survivors. The policy and procedures should be updated regularly, with professional child protection advice, and all organisations should have regular compulsory training for those in leadership positions and...
Matched on
terms: policy
CQC action
66match
The Newcastle Clinic
The service should have a system in place to confirm all staff have read existing, updated or new polices, procedure and guidance documents.
Matched on
terms: staff
IOPC learning recommendation
66match
Recommendations - South Wales Police, July 2022
The IOPC recommends the National Police Chiefs’ Council (NPCC) shares the learning from this IOPC investigation with force custody leads, asking them to take steps to ensure: Custody staff understand that the Prisoner Escort and Custody System (PECS) is a stand-alone system which does not interface with any other police systems. Therefore, any existing or new information recorded...
Matched on
terms: staff
PFD report
65match
Rajesh Parkash
Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.
Matched on
terms: staff
PFD report
65match
Arthur Fry
A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown consent requirements, potentially impacting patient care. Tighter controls are needed for procedure requisitions.
Matched on
terms: staff
PFD report
65match
Maureen Flynn
A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The patient safety investigation also failed to identify this issue.
Matched on
terms: staff
PFD report
65match
Wayne Cornlouer
An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff are now aware of its recent inclusion and proper use.
Matched on
terms: staff
PFD report
65match
Henry Holcombe
The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.
Matched on
terms: staff
PFD report
65match
Cpl Ryan Lovatt
The alcohol policy for Op Cabrit is unrealistic and poorly understood, potentially promoting binge drinking, while the critical "shark watch" role for sober supervision lacks formalization and clear communication.
Matched on
terms: policy
Committee recommendation
64match
#15 - Fourteenth Report: Readying the NHS and social care for the COVID-19 peak
The Department stressed that it had to respond quickly to the COVID-19 pandemic often with “imperfect knowledge”, which was why its approach had altered over time.43 But Care England told us that PPE guidance had changed no fewer than 40 times, causing confusion and anxiety to service providers and staff.44 When we asked why the PPE guidance had...
Matched on
terms: staff
HMICFRS recommendation
64match
FRS 2023-25 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to embed its values and associated behaviours and promote a positive workplace culture. The service has done enough to complete the following recommendations from our 2021 inspection: • improve how it engages with its staff to gain their commitment to the service’s values and associated behaviours;...
Matched on
terms: staff
IOPC learning recommendation
64match
Failure to investigate indecent exposure – Metropolitan Police Service, February 2021
The IOPC recommends that the Metropolitan Police Service (MPS) ensures that its call handlers are aware that they have discretion when assigning the length of time slots for police officers to attend car appointments for allegations of sexual offences. This follows an IOPC investigation where an Emergency Response Team (ERT) Officer attended a fast-food restaurant drive-through to conduct...
Matched on
terms: policy
Detention investigation recommendation
63match
Independent Investigation into Concerns about Brook House Immigration Removal Centre - Rec R49
The SMT with the violence reduction manager should undertake a development programme with staff to: • develop their confidence and skills in dealing with disruptive detainees; and • improve their awareness and understanding of the anti-disruption policy and how it should be implemented. (To be completed within 3 months)
Matched on
terms: awarenes, policy, staff
Committee recommendation
62match
#26 - Code of Practice for resident communication during remediation shows inconsistent practice and limited awareness
In 2023, MHCLG launched a Code of Practice to support improved communications during remediation. The HBF and the NHF told us that developers and social housing providers had agreed to follow the code. EOCS told us the code was “a long time coming” and had been heavily revised at the last minute. It told us that information on...
Matched on
terms: awarenes
IOPC learning recommendation
62match
Recommendation - Metropolitan Police Service, June 2021
The IOPC recommends that the Metropolitan Police Service (MPS) should ensure that expiration dates of protective orders; including restraining and non-molestation orders are flagged and accessible to officers attending domestic violence incidents to enable consideration of this key information into their risk assessment and decision making. The IOPC recently completed an investigation where a woman took her own...
Matched on
terms: policy
PFD report
61match
Ryan Chapman
Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.
Matched on
terms: staff
PFD report
61match
Doris Taylor
The coroner noted that staff training should include a full and clear understanding as to what constitutes a reportable incident and the managers should be aware of their duty to report such. The door-closers on all doors should be in a safe working condition.
Matched on
terms: staff
PFD report
61match
John Lowe
Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care requirements.
Matched on
terms: staff
PFD report
61match
Mark Groombridge
There was no direct communication between the local offender manager and the clinician responsible for the patient's care before the recall paperwork was issued, and there was confusion about the recall process among probation staff.
Matched on
terms: staff
PFD report
61match
Valmai West
Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.
Matched on
terms: staff
PFD report
61match
Khalid Abiaz
A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.
Matched on
terms: policy
PFD report
61match
Ash Bannister
Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking night cover lacking clear policy, leading to prolonged unsupervised periods.
Matched on
terms: policy
PFD report
61match
Susan Edwards
A critical lack of a hospital system meant prescribed mechanical thromboprophylaxis was not provided for 18 days, with no staff detecting the omission, posing a risk to patients requiring this treatment.
Matched on
terms: staff
IOPC learning recommendation
61match
Care and attention for man whilst detained in custody – Thames Valley Police, June 2021
The IOPC recommends that Thames Valley Police should remind custody officers and medical professionals that its guidance warns against medicating those withdrawing from opiates for six hours after arrival in custody due to any doubt as to what they have taken. This follows an investigation into the death of a man at Thames Valley Police police station. Thames...
Matched on
terms: policy
CQC action
60match
Elizabeth Street Surgery
Make all policies and procedures accessible to staff.
Matched on
terms: staff
HMICFRS recommendation
60match
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve understanding and awareness of the importance of equality, diversity and inclusion (EDI) and remove barriers to embedding EDI in the service. Recommendation: By 28 February 2022 the service should develop an action plan to engage with its staff to develop clear EDI objectives and...
Matched on
terms: awarenes, staff
PPO recommendation
60match
The Head of Healthcare
The Head of Healthcare should ensure that staff are aware of their responsibilities under the food refusal policy, including sharing information with prison staff and completing an incident report.
Matched on
terms: policy, staff
IOPC learning recommendation
60match
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should review current guidance and policy in relation to acting up to ensure there is transparency and clarity on how acting up positions are decided. The guidance should ensure that decisions for officers acting up are recorded, and there is an appropriate balance between short-term business needs and its commitment to equality...
Matched on
terms: policy
IOPC learning recommendation
60match
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that Northumbria Police should remind all investigative staff to pursue all lines of enquiry and that officers attending incidents document all intelligence received and upload it to policing intelligence systems. And that they are fully aware of the need to gather and record all evidence including CCTV, forensic and witness statements, which should be actively...
Matched on
terms: staff
IOPC learning recommendation
60match
Teenager took his own life after calling police for assistance – Kent Police, May 2020
The IOPC recommends that Kent Police provide clarity within their policies and guidance in relation to the grading of and dispatch to incidents where a ‘threat to life’ has been received by the control room, but no exact location is available. This follows an IOPC investigation where an unknown male made an abandoned call to police stating he...
Matched on
terms: staff
IOPC learning recommendation
60match
Recommendations - Thames Valley Police, May 2025
The IOPC recommends that Thames Valley Police (TVP) takes steps to ensure that frontline officers understand, and are confident in applying, guidance on method of entry. As part of this, the force should make clear the expectations on officers who need to force entry in an emergency situation, where they are not trained in method of entry and...
Matched on
terms: policy
IMB recommendation
60match
Berwyn (2020)
There is a need to ensure that systems and policies are consistent and fully understood both by prisoners and staff.
Matched on
terms: staff
NAO recommendation
60match
Bank of England: Managing legal, ethical and staff compliance risks
The Bank should review whether there are material differences in awareness, understanding and perception of risk and compliance between different groups of staff ? for example, based on role, seniority or length of service ? in order to identify ways to target further improvements.
Matched on
terms: awarenes, staff
CQC action
60match
Percys Travel
The service should ensure that Control of Substances Hazardous to Health (COSHH) documents are available and accessible to staff so that products can be used safely and in line with service policy.
Matched on
terms: policy, staff