Staff rota communication
Failures in communicating staff rota changes directly to staff members, relying solely on electronic system updates.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
CQC action
84match
Care Outlook (Bellerophon House)
The regional manager added this to the action plan for the service to ensure any changes to staff rotas are made through direct communication with the staff member rather than changes to the rota in the electronic system used by staff.
Matched on
terms: communication, rota, staff
PFD report
77match
Dayani Chauhan-Ahmed
The coroner noted ineffective communication regarding the length of the second stage of labour to senior staff due to an unmonitored whiteboard system. There was also uncertainty among midwifery and medical staff concerning the updated escalation policy and adherence to its time limits.
Matched on
terms: communication, staff
PFD report
73match
Matthew Crowley
The coroner identified delays in A&E assessment due to staffing and an inoperable protocol. Concerns also included on-call consultants lacking updated patient deterioration information, leading to delayed decisions and issues with transfer communication.
Matched on
terms: communication, staff
PFD report
73match
Derek Smith
The coroner noted insufficient communication between the District Nursing team, family members, and carers, alongside issues with the availability of nursing records. This limited opportunities for timely interventions and decision-making regarding Mr Smith's treatment.
Matched on
terms: communication, staff
PFD report
69match
Christopher James Morgan
The coroner raised concerns regarding the lack of communication with family and carers before changing a patient's risk level for leave, and the absence of a clear policy on staff-to-patient ratios for escorted leave from psychiatric wards.
Matched on
terms: communication, staff
PFD report
69match
Barbara White
The coroner noted a lack of clinical observations and an incorrect PARS score delaying medical intervention. Concerns also included unescalated insufficient staffing on the surgical unit and communication gaps during handover, affecting subsequent clinical consideration.
Matched on
terms: communication, staff
PFD report
69match
Tamara Holboll
The coroner identified a lack of precision in the trust's communication protocols, noting that staff lacked clear instructions on how to action identified communication needs effectively.
Matched on
terms: communication, staff
PFD report
69match
Alan Tear
Post-operative instructions were not followed by nursing staff, and rising EWS observations were not reported to medical staff. The Interventional Radiology team lacked understanding of nursing observations, highlighting a need for improved inter-team communication.
Matched on
terms: communication, staff
PFD report
69match
Martha Davies
The coroner identified serious communication failings and an over-reliance on agency and junior staff to make decisions. Concerns were also raised about the lack of a prompt response to the patient's deteriorating state and documentation issues.
Matched on
terms: communication, staff
PFD report
69match
David Moran
The coroner noted imprecise guidance for categorising referral urgency, specifically the lack of a default to urgent when screening was not possible or in cases of doubt. There were also concerns regarding ineffective communication between administrative and clinical staff.
Matched on
terms: communication, staff
PFD report
69match
Catherine Kennedy
The coroner identified that robust measures are not consistently in place to reduce miscommunication between ward staff and on-call doctors. This includes the absence of a consistent communication paradigm (such as SBAR) for telephone conversations.
Matched on
terms: communication, staff
PFD report
69match
Bradley Morgan
The coroner noted a communication breakdown between mental health teams led to a patient not receiving follow-up care. Concerns were raised that high staff caseloads and chronic underfunding of mental health services continue to pose a risk.
Matched on
terms: communication, staff
PFD report
69match
Mary Johnson
The coroner noted a lack of communication among staff regarding pre-operative patient feeding and medication adherence, alongside concerns that porter availability affected the hospital's capacity to perform operations.
Matched on
terms: communication, staff
Committee recommendation
69match
#132 - 2nd Report - Growing pains: clarity and culture change required - An examination of the secondary...
The FCA and PRA must review how their supervisory staff are deployed to ensure greater consistency in the staffing of supervisory teams and to address reports of frequent rotation amongst supervisors. A lack of proportionality in regulation and supervision
Matched on
terms: rota, staff
Committee recommendation
69match
#126 - 2nd Report - Growing pains: clarity and culture change required - An examination of the secondary...
However, low aggregate turnover does not necessarily guarantee continuity in the important supervisory function. Indeed, David Bailey, Executive Director for Prudential Policy at the PRA, noted that staff rotations are inherent to the PRA’s supervisory approach: “We need the supervisors to turn over on individual firms. We do not need that on a frequent basis, but they need...
Matched on
terms: rota, staff
Committee recommendation
69match
#122 - 2nd Report - Growing pains: clarity and culture change required - An examination of the secondary...
Several witnesses cited the frequent rotation of staff in supervisory teams as a concern. TheCityUK told us that: “Poor understanding of firms’ business models is exacerbated by regular churn in supervisory teams.” 196 We received evidence that frequent rotation requires firms to invest significant time and resources into rebuilding relationships with their supervisory teams and developing new supervisors’...
Matched on
terms: rota, staff
CQC action
65match
North Middlesex University Hospital
The services should improve communication with staff regarding staffing decisions.
Matched on
terms: communication, staff
CQC action
65match
Holly House Residential Care Home
The provider must ensure that staffing rotas accurately demonstrate staffing numbers, reflect all shifts worked, and reconcile with payroll records and actual hours worked.
Matched on
terms: rota, staff
CQC enforcement action
65match
Warning Notice: Barts Health NHS Trust
The Care Quality Commission (CQC) told Barts Health NHS Trust that improvements are needed in the diagnostic imaging departments at The Royal London Hospital and Whipps Cross University Hospital. Following a focused inspection in May, CQC found serious concerns including unsecured hazardous clinical equipment, a hostile working environment, and issues with ageing equipment and staff rotas. CQC instructed...
Matched on
terms: rota, staff
PFD report
61match
Brian Belfield
The coroner identified a lack of robust systems for tracking and reconciling race participant numbers, meaning a missing runner was not identified. Concerns also included insufficient communication between race control and marshals.
Matched on
terms: communication
PFD report
61match
Ryan Boyle
The coroner identified a need for improved training for force control operators on police pursuit policies and responsibilities. Concerns were also raised regarding the lack of an efficient notification system for pursuits and insufficient staffing on the 'Force desk'.
Matched on
terms: staff
PFD report
61match
Mohammad Ashraf
The coroner identified inadequate and delayed allergy care plans for pupils, ineffective communication between the school and caterer, and an unsafe allergy identification system. Crucially, the Local Authority did not communicate safety recommendations to the school.
Matched on
terms: communication
PFD report
61match
Philip Powell
The coroner identified delays in ordering Debrisoft for wound management and poor communication, alongside confusing systems, regarding its procurement process and overall responsibility.
Matched on
terms: communication
PFD report
61match
Muhammed Haleem
Information on the NWAS system for paramedic guidance was outdated, and there was a lack of communication between community paediatric teams and emergency services regarding DNA-CPR orders for children.
Matched on
terms: communication
CQC action
60match
Fleetwood Hospital
The services should consider how communication with all staff can be improved so that they are kept fully informed of key issues affecting their service and are more engaged.
Matched on
terms: communication, staff
CQC action
59match
Monaveen
The provider must ensure governance systems sustain improvements and address failures in communication and engagement with people and staff.
Matched on
terms: communication, staff
PFD report
57match
Nicola Matthews
The coroner identified incomplete documentation of ward round decisions and a lack of clear, documented follow-up arrangements for patients discharged from inpatient care, particularly those at risk of self-harm. This meant staff lacked clarity on discharge plans and medication.
Matched on
terms: staff
PFD report
57match
Sean Seabourne
The coroner noted insufficient formal communication and clarity of roles between mental health teams, which meant critical information about a patient's settled plans to kill himself was not adequately shared or acted upon.
Matched on
terms: communication
PFD report
57match
Joanne Manning
The coroner raised concerns about the lack of established communication procedures between general practitioners and secondary care prescribers of methadone, which led to a psychiatrist not receiving crucial patient medical information from the GP practice.
Matched on
terms: communication
PFD report
57match
Archie Hexall
The coroner noted a breakdown in communication between midwives regarding signs of respiratory distress, and the initial observation records were not retained. Parents were also not informed of concerns about their child's breathing, limiting their opportunity to contribute to care.
Matched on
terms: communication
PFD report
57match
Brian Gillard
The coroner identified insufficient handover procedures regarding a patient's need for ambulatory oxygen during transfer between hospital departments. This led to ward staff being unaware of the patient's oxygen requirements, and portable oxygen not being used when he went to the toilet.
Matched on
terms: staff
PFD report
57match
Freda Weston
Insufficient doctor and nurse staffing led to significant delays in antibiotic administration and patient review. The report also notes issues with adherence to escalation guidelines, clarity of pharmacy medication details, and immediate shredding of handover sheets.
Matched on
terms: staff
PFD report
57match
Winifred Elliott
The coroner noted that removing resident transfer information from display in rooms made it harder for staff to access, potentially leading to inappropriate transfers and injuries. There were concerns about the CQC's role in advising homes to implement and display such information.
Matched on
terms: staff
PFD report
57match
Jane Stables
The coroner identified ineffective communication between nurses and the general practitioner regarding ongoing significant pain levels that were impeding care provided.
Matched on
terms: communication
PFD report
57match
John Atkinson
The coroner identified gaps in updating patient risk assessments, managing patients when care co-ordinators depart, and effective communication among mental health professionals. Difficulties for psychiatrists in accessing Home Treatment Team Services were also noted.
Matched on
terms: communication
PFD report
57match
Patrick Steer
Concerns were raised regarding inadequate communication between Surgical and Coronary Care teams for patients under shared care, and the absence of a clear Trust policy to manage this interaction.
Matched on
terms: communication
PFD report
57match
Doreen Wilkins
The coroner raised concerns that carer rotas do not always allow for travel time, which may lead to late arrivals for time-critical visits or carers cutting short visits, resulting in clients not receiving their assessed duration of care.
Matched on
terms: rota
PFD report
57match
Gail Bailey
The coroner identified concerns regarding an apparent breakdown in communication for emergency admissions, noting that despite pre-alert calls, hospital clinicians appeared unprepared and specialist teams were not forewarned of the patient's arrival.
Matched on
terms: communication
PFD report
57match
Calary Davis
An incomplete action plan from a root cause analysis, risks from a maternity service merger, and a culture of not performing specific procedures at night were noted. Additional concerns included insufficient staffing levels and leadership gaps.
Matched on
terms: staff
PFD report
57match
Rebecca Hursey
The coroner raised concerns regarding the need for clinical record-led handovers focusing on risk, verbal communication of increased suicidal risk, timely and prioritised alternative placements for high-risk patients, and inter-unit sharing of complex cases.
Matched on
terms: communication
Committee recommendation
57match
#123 - 2nd Report - Growing pains: clarity and culture change required - An examination of the secondary...
We received evidence that frequent personnel changes in a firm’s supervisory team reduce the pace of supervision. Aon told us that: “the high turnover of the FCA means supervisory teams are frequently changing; new supervisors are having to familiarise themselves with their brief quickly, which can lead to a delay in decision-making.” 198 Such delays in decision-making may...
Matched on
terms: staff
Committee recommendation
57match
#114 - 2nd Report - Growing pains: clarity and culture change required - An examination of the secondary...
Witnesses suggested that there were inconsistencies in the quality of supervision and an overdependence on rigid and inefficient supervisory processes, increasing the demands placed on firms. Witnesses told us that the frequent rotation in supervisory teams can disrupt the continuity in the relationships between firms and their supervisors, undermining the predictability needed to invest and grow. A lack...
Matched on
terms: rota
ICIBI recommendation
55match
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 4 Produce an improvement plan for internal communications at Stansted that reduces the reliance on email, ensures ‘top down’ messages reach and are understood by all affected staff, and that staff have a means of communicating upwards that is seen to be effective.
Matched on
terms: communication, staff
ICIBI recommendation
55match
An inspection of Border Force operations at Stansted Airport
Recommendation 4 Produce an improvement plan for internal communications at Stansted that reduces the reliance on email, ensures ‘top down’ messages reach and are understood by all affected staff, and that staff have a means of communicating upwards that is seen to be effective.
Matched on
terms: communication, staff
IMB recommendation
55match
Sudbury (2024)
The Board has continued to note that some prisoners perceive there to be inconsistencies between the OMU staff, in terms of processing ROTL applications, but also acknowledges the recent changes to the systems in use and the appointment of additional management in the area. An ongoing concern raised by prisoners is the lack of regular communication between them...
Matched on
terms: communication, staff
HSSIB recommendation
53match
Detection of retained vaginal swabs and tampons following childbirth
It would be beneficial for trusts to review their planned handovers and for all staff groups to have adequate time in their shift to conduct handover tasks and participate in team briefings. Practices at the end of tasks
Matched on
terms: staff
HSSIB recommendation
53match
Patients at risk of self-harm: continuous observation
Is there a clear and comprehensive process for handing over a patient’s care to staff on the receiving ward?
Matched on
terms: staff
CQC action
52match
Affinity Trust Specialist Support Division North
People's needs and any changes in their care and support was not always shared with staff.
Matched on
terms: staff
IOPC learning recommendation
52match
Care and attention for man whilst detained in custody – Thames Valley Police, June 2021
The IOPC recommends that Thames Valley Police ensures arrangements are in place for all custody officers, staff and HCPs to receive information about detainees when their shift starts. This follows an investigation into the death of a man at a Thames Valley Police police station. One of the detention officers involved in the observation of the detainee began...
Matched on
terms: staff
IOPC learning recommendation
52match
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police clarify and/or implement/formalise an escalation process when there are outstanding matters to be resourced. Due to the lack of policy, some staff members inform their supervisors whilst other do not. This incident was left outstanding for 26 hours. The IOPC is aware that Derbyshire have implemented some fast track learning around this...
Matched on
terms: staff