Care home infection control
Failure to safely follow infection prevention and control (IPC) practices in care homes, risking outbreaks and resident health.
336 items
10 sources
3 inquiries
Source spread
Where this theme appears
Care home infection control has been flagged across 10 independent accountability sources:
24 inquiry recs
25 PFD reports
18 committee recs
128 CQC actions
1 PPO rec
30 IMB recs
2 patient safety alerts
5 detention investigation recs
30 PHSO decisions
73 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
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 (24)
R66 — Healthcare environment maintenance
Recommendation: Health Boards should ensure that the healthcare environment does not compromise effective IPC, and that poor maintenance practices are not tolerated.
Gov response: Section 3.1 of the Scottish Government's response highlights the revised NHSScotland National Cleaning Services Specification and its monitoring framework, which enables NHS boards to assess and improve the physical healthcare environment. Significant investment has been …
Accepted
R65 — Isolation for infectious diarrhoea
Recommendation: Health Boards should ensure that appropriate steps are taken to isolate patients with potentially infectious diarrhoea.
Gov response: Section 2.1 of the Scottish Government's response details the Standard Infection Control Precautions (SICPs), which are basic measures to reduce the risk of germ transmission. Among the 10 SICPs is "Patient placement in wards and …
Accepted
R63 — Effective CDI patient isolation
Recommendation: Health Boards should ensure that there is effective isolation of any patient who is suspected of suffering from CDI, and that failure to isolate is reported to senior management.
Gov response: Section 3.1 of the Scottish Government's response addresses patient isolation through the requirement for all planned new-build hospitals to provide 100% single-room accommodation, and refurbished builds at least 50%. This measure significantly reduces the risk …
Accepted
R60 — Cleanliness Champions implementation
Recommendation: Health Boards should ensure that programmes designed to improve staff knowledge of good infection prevention and control practice, such as Cleanliness Champions Programme, are implemented without undue delay.
Gov response: Section 4.3 of the Scottish Government's response confirms that the Cleanliness Champions Programme was introduced in September 2003, with over 18,000 NHS Scotland staff having completed it. The program aims to prepare staff to promote …
Accepted
R67 — Link Nurse training
Recommendation: Health Boards should ensure that, where a local Link Nurse system is in place as part of the IPS system, the Link Nurses have specific training for that role.
Gov response: Section 4.3 of the Scottish Government's response describes the HAI Taskforce's support for education, which includes a strategy to ensure all healthcare workers receive appropriate education and training related to HAI. It also promotes an …
Accepted
R64 — Cohorting only exceptional
Recommendation: Health Boards should ensure that cohorting is not used as a substitute for single room isolation and is only resorted to in exceptional circumstances.
Gov response: Section 3.1 of the Scottish Government's response outlines a policy to increase single-room accommodation in hospitals. All planned new-build hospitals are now required to provide 100% single-room accommodation, and refurbished hospital builds must ensure at …
Accepted
R62 — Senior manager clinical visits
Recommendation: Health Boards should ensure that senior managers accompanied by IPC staff visit clinical areas at least weekly to verify that proper attention is being paid to IPC.
Gov response: Section 3.1 of the Scottish Government's response details the 10 Patient Safety Essentials, which include leadership walk-rounds. These walk-rounds involve leaders, including executive and non-executive directors, and frontline staff discussing and reducing barriers to reliably …
Accepted
R61 — Unannounced inspections with lay representation
Recommendation: Health Boards should ensure that unannounced inspections of clinical areas are conducted by senior infection prevention and control staff accompanied by lay representation.
Gov response: Section 2.1 of the Scottish Government's response highlights the role of the Healthcare Environment Inspectorate (HEI), established in April 2009, which conducts at least 30 unannounced inspections annually in acute and other healthcare settings. To …
Accepted
R59 — Priority attendance at IPC meetings
Recommendation: Health Boards should ensure that attendance by members of committees in the infection prevention and control structure is treated as a priority.
Gov response: Section 2.1 of the Scottish Government's response states that reducing HAI is a priority, leading to a wide range of measures driven by the national HAI Taskforce. This Taskforce has been restructured to provide efficient, …
Accepted
R52 — IPC policy adherence audits
Recommendation: Health Boards should ensure that adherence to infection prevention and control polices, for example C. difficile and Loose Stools Policies, is audited at least annually.
Gov response: Section 3.3 of the Scottish Government's response states that quality improvement uses a range of methods, such as audit, to deliver change and improve outcomes. Section 2.1 details that a robust HAI scrutiny regime is …
Accepted
R50 — 24/7 IPC cover
Recommendation: Health Boards should ensure that there is 24-hour cover for infection prevention and control seven days a week, and that contingency plans for leave and sickness absence are in place.
Gov response: Section 4.1 of the Scottish Government's response discusses general workforce planning, including the use of nursing and midwifery workload and workforce planning tools to determine the number of nurses or midwives needed. However, the provided …
Accepted
R43 — IPC staff regular training
Recommendation: Health Boards should ensure that Infection Control Nurses and Infection Control Doctors have regular training in infection prevention and control of which a record should be kept.
Gov response: Section 4.3 of the Scottish Government's response notes that the HAI Taskforce delivery plan included an education framework for specialists working in infection prevention and control. For nurses, accredited education programmes for specialist and advanced …
Accepted
R42 — Mandatory IPC training
Recommendation: Health Boards should ensure that all those working in a healthcare setting have mandatory infection prevention control training that includes CDI on appointment.
Gov response: Section 4.3 of the Scottish Government's response states that the HAI Taskforce delivery plan promoted a strategy to ensure all healthcare workers receive appropriate education and training related to HAI. The Cleanliness Champions Programme, which …
Accepted
R9 — IPC clinical governance meetings
Recommendation: Health Boards should ensure that infection prevention and control is explicitly considered at all clinical governance committee meetings from local level to Board level.
Gov response: Section 2.2 and 3.2 of the Scottish Government's response confirm that the infection control manager is an integral member of the organisation's infection prevention control, clinical governance, and risk management committees. Section 3.2 further states …
Accepted
R3 — IPC policy review
Recommendation: Health Boards should ensure that infection prevention and control policies are reviewed promptly in response to any new policies or guidance issued by or on behalf of the Scottish Government.
Gov response: Section 2.1 and 3.2 of the Scottish Government's response indicate that NHS boards are required to adhere to revised Healthcare Associated Infection (HAI) Standards and the National Infection Prevention and Control Manual, with performance against …
Accepted
R73 — OCT report detail sufficiency
Recommendation: Health Boards should ensure that OCT3 reports provide sufficient details of the key factors in the spread of infection to allow a proper audit to be carried out.
Gov response: Section 4.2 notes the report's recommendation that Outbreak Control Team (OCT3) reports should provide sufficient detail on key factors in infection spread to allow proper auditing (recommendation 73). While the "Our current position" section details …
Accepted
R53 — Surveillance systems fit for purpose
Recommendation: Health Boards should ensure that surveillance systems are fit for purpose, are simple to use and monitor, and provide information on potential outbreaks in real time.
Gov response: Section 2.1 of the Scottish Government's response details that national and local surveillance data are collected across a range of areas to support and monitor HAI policy, including data for HAI outbreaks. Section 4.2 further …
Accepted
R17 — Ward admission responsibility
Recommendation: Health Boards should ensure that where there is risk of cross infection, the nurse in charge of a ward has ultimate responsibility for admission of patients to the ward or bay.
Gov response: Section 2.1 of the Scottish Government's response details the Standard Infection Control Precautions (SICP) which are basic infection prevention and control measures. One of the ten SICPs is "Patient placement in wards and bays," directly …
Accepted
R12 — CDI infection control advice
Recommendation: Health Boards should ensure that when a patient has CDI patients and relatives are given clear and proper advice on the necessary infection control precautions.
Gov response: Section 4.2 of the Scottish Government's response highlights initiatives to improve patient and family communication. The Person-centred Health and Care Collaborative's "Must Do with Me" elements include ensuring patients receive the information they need, which …
Accepted
F240 — Hygiene
Recommendation: All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged to remind anyone, however senior, of these.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
R20 — Stool records for CDI patients
Recommendation: Health Boards should ensure that where a patient has, or is suspected of having, C.difficile diarrhoea a proper record of the patient's stools is kept.
Gov response: Section 4.2 of the Scottish Government's response outlines the professional standards for record-keeping for nurses. The revised NMC code requires nurses and midwives to complete all records accurately and without any falsification, and to identify …
Accepted
R16 — CDI outbreak reporting
Recommendation: Health Boards should ensure that the nurse in charge of each ward reports suspected outbreaks of CDI (as defined in local guidance) to the Infection Control Team.
Gov response: Section 2.1 of the Scottish Government's response highlights a robust HAI scrutiny regime across NHS Scotland, which drives improvements in infection control and prevention practices. The National Infection Prevention and Control Manual, introduced in January …
Accepted
R2 — HAI implementation strategy
Recommendation: Scottish Government should ensure that policies and guidance on healthcare associated infection are accompanied by an implementation strategy and that implementation is monitored.
Gov response: Section 2.1 of the Scottish Government's response highlights that Revised Healthcare Associated Infection (HAI) Standards were published in February 2015, which NHS boards will adopt from May 2015, with performance against them forming part of …
Accepted
SHI-11 — Training for IPC professionals engineers and clinicians
Recommendation: I would recommend that IPC professionals should receive some basic training on the recommendations made by the NHS's own guidance for engineering systems, insofar as they are made in the interests of patient safety and care, before they are recruited …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025. Progress update 17 September 2025: NHS Scotland Assure is developing a framework of training and lessons learned that will be accessible …
Accepted
In progress
PFD Reports (25)
Wilhelmina Isobel Newton
Concerns: The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly residents, particularly those on anti-clotting medication.
Response (Cumbria County Council): Cumbria County Council has reviewed the issues regarding procedures to be followed when a resident sustains or is suspected of sustaining a head injury and updated their policy, embedding it …
Responded
Barbara Cooke
Concerns: Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had no system to record safeguarding alerts or notify authorities of deaths for vulnerable patients.
Overdue
Martin Dean
Concerns: Inadequate adherence to hand hygiene by visitors on a Critical Care Ward, directly increasing the risk of infection to vulnerable patients.
Overdue
Margaret Clarke
Concerns: There is a lack of guidance for the effective cleaning of fixed shower heads, which are increasingly common in private and public leisure facilities.
Response (Health and Safety Executive): The HSE states it has no enforcement powers under the General Product Safety Regulations regarding showerheads and has passed the coroner's letter to the local Trading Standards Department.
Response (Doncaster Borough Council): The council explains its duties under the Consumer Protection Act and General Product Safety Regulations, noting the absence of specific regulations for showerheads. They suggest the HSE review guidance regarding …
Responded
Eliza Simpson
Concerns: The care home lacked a system for renewing deprivation of liberty orders, risking unauthorized detention. The absence of CCTV also hindered investigation into an absconding resident.
Overdue
May Hall
Concerns: Care home staff lacked awareness and clear training on fall reporting policies and how to contact emergency services, indicating a need for regular, confirmed training.
Overdue
Thomas Nicholls
Concerns: The report identifies care staff lacking training in PEG feeding, specifically regarding mobility and handling, and the failure to report a related incident, prompting a review of policies and training.
Overdue
Elsie Brown
Concerns: Absent falls/bed rails assessments, incomplete care plans, poor record-keeping, inadequate night staffing, and informal handovers created significant safety risks due to unclear staff responsibilities.
Overdue
Alwyn Head
Concerns: Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.
Response (A head): The Trust introduced new admission/transfer documentation for patient infection status, is providing staff training, and implemented ward-to-board rounds. A Deteriorating Patient Programme and a Sepsis Action Group are in place, …
Responded
Ronald Farrington
Concerns: The care centre failed to implement specialist nursing advice, kept inaccurate records, and didn't seek medical attention for infection, exacerbated by inadequate tissue viability nurse staffing and poor CQC oversight.
Response: Surrey County Council has improved systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion, and has reduced the percentage of enquiries …
Response (Ronald Farrington): The care home has implemented structures and processes to avoid similar situations, including computerized care plans for wound and tissue care, regular reviews, and updates based on professional visits, audited …
Overdue
John Edwards
Concerns: The care home was unable to manage complex needs, demonstrating inadequate policies for falls and pressure sores, poor record-keeping, and a failure to administer prescribed medication or seek timely medical assistance for deterioration.
Response (Response Southwinds Limited): Response Southwinds Limited disputes the implication that neglect contributed to the death of Mr. Edwards, argues that other evidence was not sufficiently taken into account, and asserts that they were …
Overdue
Andrew Clegg
Concerns: Care homes are rarely designed with water safety in mind, and CQC inspectors lack sufficient training to identify legionella risks in water systems.
Response: The CQC confirms that water safety is considered by its inspectors and that they check for Legionella risk assessments. The Construction Industry Council is pressing for all aspects of life …
Overdue
Irene Collins
Concerns: Unrestricted access and disposal of clinical examination gloves in care settings pose a risk, particularly for residents with cognitive impairment who can easily access them.
Overdue
Joan Sanderson
Concerns: The provided text details the deceased's medical history and cause of death but does not articulate specific coroner's concerns regarding future deaths.
Response (GM Health and Social Care Partnership and Healthcare Safety Investigation Branchwillbe): The GM Health and Social Care Partnership notes that the Regulation 28 letter has also been sent to HSIB and will leave it to the named respondent to address the …
Overdue
Anthony Slack
Concerns: The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), and staff confusion over PPE. Ambulance delays also impacted patient transfer.
Response (NHS England and NHS Digital): NHS England liaised with the North West Ambulance Service (NWAS) who have since extended their cleaning service to sixteen Emergency Departments across the North West, including Tameside Hospital, to improve …
Response (UK Health Security Agency): PHE acknowledges the coroner's report and outlines its national activities coordinating the response to COVID-19 in adult social care settings, including surveillance, guidance development, and stakeholder engagement. It states that …
Response (CQC): CQC reviewed systems at The Vicarage Residential Care Home and is assured that the provider has taken action to improve and further reduce risks, which will be reviewed at the …
Response (Greater Manchester Health and Social Care Partnership): Greater Manchester Health and Social Care Partnership will present learning to the Greater Manchester Quality Board. They have established an Infection Prevention and Control Care Home Cell, are running monthly …
Response (Vicarage Care Home): The Vicarage Care Home has provided documentation training to staff, updated the documentation and recording policy, reissued relevant documentation pro formas, and updated the protocol regarding waiting times for emergency …
Responded
Alvin Black
Concerns: The report identifies concerns about the poor state of cleanliness at the prison's Health Care Centre, potentially increasing the risk of infection for prisoners; it also notes a missed opportunity to consider anti-coagulation therapy, with the system not picking up on this error.
Overdue
Joyce Dennis
Concerns: Lack of continuous oversight, inadequate staff training in recognizing subtle signs of illness in the elderly, and poor documentation and communication within the care home created significant risks.
Overdue
Lilian Behrendt
Concerns: The care home exhibited abysmal record-keeping, failing to document patient deterioration or observation results. Issues included insufficient mobile recording devices, lack of staff accountability, and unclear DNACPR status.
Response (Kingsley Healthcare): Kingsley Healthcare has removed pre-loaded 'emotionally-charged' words from their electronic care management software, requiring staff to manually describe resident presentation. They have also implemented a new system across all homes …
Overdue
Karen Starling and Anne Martinez
Concerns: Hospital water systems are contaminated with M abscessus, posing a serious risk to immunosuppressed patients. Existing water safety guidance is inadequate, lacking specific protocols for identifying and controlling mycobacteria in hospital settings.
Response (NHS England): NHS England has commissioned a review of HTM 04-01 by Dr Susanne Surman-Lee, specifically related to immunosuppressed patients and NTM, including identifying any specific measures required for new hospital premises, …
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges the concerns and states that NHS England is the correct organisation to respond, noting that NHSE already sent a response on Feb …
Responded
Sylvia Nash
Concerns: Insufficient understanding and communication between agencies regarding multi-disciplinary decision-making for patient care, particularly observation removal, led to confusion over responsibilities and incorrect procedures.
Response: Connaught House states they assessed Sylvia required 1:1 supervision and communicated this, but that funding for 1:1 observations is a wider issue. They claim the Regulation 28 order is unfair …
Response (Birmingham City Council): BCC has conducted staff engagement sessions and provided a template for recording multi-disciplinary decision making. The ICB is leading on developing procedures around 1 to 1 support in P2 beds, …
Response: Connaught House has cascaded information about a new ICB process for removing 1:1 support to their staff and placed posters in each nursing station to ensure awareness.
Responded
Terence Hines
Concerns: Failures in hospital cleaning protocols led to a patient acquiring MRSA from a previously occupied room. Multiple failures to perform routine MRSA screening before and during his inpatient stay also contributed to a fatal infection.
Response (Worcestershire Acute Hospitals): The Trust updated its Isolation Policy to require a Red clean for every known case of MRSA and distributed a "lessons learned" poster to wards to highlight learning from the …
Responded
Joan Blaber
Concerns: Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication of protocols, and a lack of reporting unsafe practices.
Response (Brighton and Sussex University Hospitals): The Trust has revised COSHH procedures with updated folders and training that includes anonymised inquest evidence. The roles of Hosts and Housekeepers have been split and clarified and Datix incident …
Responded
Patricia Lines
Concerns: Outdated national guidance led to a nurse not cleaning skin before an injection, potentially increasing infection risk due to lack of disinfection and reliance on 20-year-old evidence.
Response (NHS England): NHS England acknowledges the concerns and will review UKHSA's response, while highlighting existing IPC guidance aligning with 'The Green Book' and planned discussions by the Regulation 28 Working Group.
Response (UK HSA): The UKHSA expresses condolences and explains its role in iGAS notification and investigation. It states that it has no plans to amend the 'Green Book' guidance regarding alcohol wipes prior …
Response (Browney House Surgery): Browney House Surgery will use the case as a learning exercise, staff will attend Infection Prevention and Control courses, enroll into an Injection Administration Training course and follow local and …
Response (Department of Health and Social Care): DHSC has determined that UKHSA is better positioned to address the issues raised in the report, as responsibility for guidance on immunization procedures lies with them.
Responded
Walter Horton
Concerns: Concerns include poor record keeping for falls, wound management, and handover, alongside a failure to follow aseptic techniques for wound care, increasing infection risk.
Response (Doncaster Bassetlaw NHS Foundation Trust): The Trust acknowledges the concerns raised in the PFD report regarding the death of Mr. Horton, but states that a falls risk assessment was completed and wound care was delivered …
Responded
Barbara Wingate
Concerns: Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute care.
Responded
Committee Recommendations (18)
#51 —
Recommendation: The Government should review the provision of infection prevention and control measures, including infection prevention and control nurses, to social care and ensure that social care providers, particularly care homes, are able to conduct regular pandemic preparedness drills. The Government …
Gov response: The government accepts this recommendation. Recommendation 296 is about the government reviewing the provision of infection prevention and control measures to social care and ensuring that social care providers, particularly care homes, are able to …
Under Consideration
#46 —
Recommendation: Staff shortages, the lack of testing, difficulties in obtaining PPE and the design of care settings to enable communal living hampered isolation and infection control and the ability to keep covid at bay. Social care staff in care homes and …
Gov response: The government recognises and has responded to the impact of the pandemic on the social care sector. The Prime Minister’s announcement of the ‘Build Back Better’ plan for health and social care in September 20213 …
Under Consideration
#51 —
Recommendation: The Government should review the provision of infection prevention and control measures, including infection prevention and control nurses, to social care and ensure that social care providers, particularly care homes, are able to conduct regular pandemic preparedness drills. The Government …
Gov response: The government accepts this recommendation.
Under Consideration
#28 — NHS staff inconsistently adhere to basic infection prevention and control procedures.
Recommendation: We asked about issues with infection prevention and whether some of the basics were not being upheld as much as they should. DHSC said that we should not underestimate how much of the battle against AMR “is really basic things”, …
Gov response: 5.1 The government agrees with the Committee’s recommendation Target implementation date: Summer 2026 5.2 The government is prioritising AMR and infection control across the healthcare system. This includes embedding AMR into national and regional strategies, …
Accepted
#27 — Hospital-acquired C. difficile and MRSA infections reach multi-year highs across NHS.
Recommendation: An essential part of reducing the threat of AMR in humans is the day-to- day work of the NHS in preventing and controlling infections, such as good hygiene practices, aseptic technique and high standards of cleanliness, which can limit the …
Gov response: 5.1 The government agrees with the Committee’s recommendation Target implementation date: Summer 2026 5.2 The government is prioritising AMR and infection control across the healthcare system. This includes embedding AMR into national and regional strategies, …
Accepted
#7 —
Recommendation: The Government must ensure that standards for weekly testing for care home staff are maintained including rapid turnaround times and that regular data is published on the number of tests delivered to social care staff and residents. In addition, the …
Gov response: 6.5 Making tests available is a key part of the Government’s ongoing plan to tackle COVID-19. This relates to several contexts in adult social care: Care Homes Care homes are on the frontline in the …
Under Consideration
#45 —
Recommendation: The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the …
Gov response: The government recognises and has responded to the impact of the pandemic on the social care sector. The Prime Minister’s announcement of the ‘Build Back Better’ plan for health and social care in September 20213 …
Under Consideration
#31 —
Recommendation: The resulting requirement to abandon testing people in the community during the critical early period of the pandemic cost many lives for a number of reasons including because: a) many asymptomatic carriers were not tested and therefore identified and asked …
Under Consideration
#15 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Gov response: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access …
Under Consideration
#45 —
Recommendation: The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the …
Gov response: The government recognises and has responded to the impact of the pandemic on the social care sector. The Prime Minister’s announcement of the ‘Build Back Better’ plan for health and social care in September 20213 …
Under Consideration
#31 —
Recommendation: The resulting requirement to abandon testing people in the community during the critical early period of the pandemic cost many lives for a number of reasons including because: a) many asymptomatic carriers were not tested and therefore identified and asked …
Gov response: The government partially accepts this recommendation. The government agrees that there is positive learning and engagement to be had with other countries, practitioners, and disciplines, as it has done since the start of the pandemic …
Under Consideration
#15 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Gov response: The government accepts this recommendation. The NHS is committed to developing and publishing new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. NHS England and NHS Improvement published …
Under Consideration
#72 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Gov response: The experience of the demands placed on the NHS during the COVID-19 pandemic should lead to a more explicit, and monitored, surge capacity being part of the long term organisation and funding of the NHS. …
Under Consideration
#46 —
Recommendation: Staff shortages, the lack of testing, difficulties in obtaining PPE and the design of care settings to enable communal living hampered isolation and infection control and the ability to keep covid at bay. Social care staff in care homes and …
Gov response: The government recognises and has responded to the impact of the pandemic on the social care sector. The Prime Minister’s announcement of the ‘Build Back Better’ plan for health and social care in September 20213 …
Under Consideration
#72 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Gov response: The government accepts this recommendation. NHS England is committed to developing and publishing new protocols for infection prevention and control in pandemics, covering staffing, bed capacity, and physical infrastructure. In developing these protocols, NHS England …
Under Consideration
#2 —
Recommendation: The Government provided vital additional funding to the adult social care sector during the pandemic, and we appreciate that the additional covid-19 funding cannot continue indefinitely. However, the Government’s own guidance that care workers should self-isolate if they test positive …
Gov response: The 2021 Spending Review settlement considered a wide range of pressures facing social care. However, we recognise that since then there has been increased short-term pressure on local authorities’ ability to deliver adult social care, …
Accepted
#23 —
Recommendation: Care England and the British Medical Association told us that the contingency planning process for a pandemic appeared to focus on the NHS at the expense of the social care sector despite some of the most vulnerable people being in …
Gov response: 4: PAC conclusion: The Department’s focus on supporting hospitals meant assistance to social care providers was neglected. 4: PAC recommendation: The Department should write to the Committee by the end of April 2021 to explain …
Not Addressed
#15 —
Recommendation: We welcome the proposals for a licensing scheme put forward in the Government’s consultation, including the proposed categories and the need for a practitioner to acquire appropriate indemnity cover and premises which meet the necessary standards of hygiene, infection control …
Response Pending
CQC Inspection Actions (128) — showing 50 strongest matches
Cotton Exchange
The provider must have processes that assess the risk of, and prevent, detect, and control the spread of, infections, including those that are healthcare associated.
Must Do
Victoriana Care Home
People were at risk of experiencing harm as there were shortfalls in how to prevent cross contamination in the home. Processes for managing Covid19 did not always reflect government guidelines. There were some potential infection control risks.
Must Do
Valewood House Nursing Home
People were not protected against identifiable risks of infection because standards of cleanliness and hygiene were inadequate.
Must Do
Southwinds
The premises was not visibly clean and free from odours that were offensive or unpleasant.
Must Do
Pennsylvania House
The provider must ensure people who use services and others are protected against the risks associated with the control and spread of infection by adequate maintenance and infection control procedures.
Must Do
Oaklands Care Home
The provider failed to ensure the homes environment was clean and free from offensive odours.
Must Do
Haisthorpe House
The provider must ensure people who used services are protected against the risk of exposure to healthcare associated infections because the provider operates a system to assess the risk and prevent, detect and control the spread of infection, and maintains …
Must Do
Unit 4 Cornishway Industrial Estate
Provide care and treatment in a safe way for service users by assessing the risk of, and preventing, detecting and controlling the spread of, infections.
Must Do
Adey Gardens Care Home
People who use services and others were not protected against the risks associated with control of infection because the provider did not ensure that the premises were a clean and hygienic environment for the people who lived there.
Must Do
The Elms
The provider had failed to have effective systems in place to assess, prevent, detect and control the spread of infections, assess and mitigate risks to people's health, safety and wellbeing and had failed to ensure the safe and proper management …
Must Do
Suffolk House
The provider failed to ensure people were protected from the spread of infection and systems in place did not ensure risks were managed safely.
Must Do
Station House
The provider must ensure that hygiene practices ensure people's safety.
Must Do
St Marys Nursing Home
The provider must ensure the environment is maintained to ensure people are safe from risk of infection.
Must Do
St Marys Care Centre
The provider must ensure effective infection and prevention control measures are in place and individual risks to people are effectively identified or mitigated.
Must Do
Private Ultrasound Scan
The service must ensure that staff control infection risks well. This includes using appropriate sterile ultrasound gel in line with national guidelines and conducting infection prevention and control audits.
Must Do
Norton Lees Hall and Lodge
The provider had failed to ensure infection, prevention and control policies and procedures were always followed.
Must Do
Meet The Baby
The provider should ensure that regular hand hygiene and infection prevention and control audits are carried out on staff undertakings scans to ensure compliance with infection control and hygiene techniques.
Should Do
Kings Den
Covid- 19 government guidance in relation to infection prevention control was not always followed.
Must Do
Hulton Care Home
The provider must ensure infection prevention and control (IPC) practices are being safely followed.
Must Do
Graceland Care Home
The provider must ensure safe care and treatment by sufficiently protecting people from the potential spread of infections.
Must Do
Enstone House
Systems had not been established to ensure safe infection control practices were maintained.
Must Do
East Cosham House
There was a failure to prevent the risk of, detect and control the spread of infections. Some equipment was not included on cleaning schedules and was visually dirty.
Must Do
Cosham Court Nursing Home
The provider failed to ensure infection and prevention control measures were effectively managed or people were protected from the risk of harm.
Must Do
Cherished Moments
The service must ensure hand hygiene and environmental cleaning audits are carried out.
Must Do
Chandos Lodge Nursing Home
The service had not fully implemented robust infection prevention and control procedures to effectively mitigate risk to people. We found evidence safe medicine practices were not always promoted in relation to storage and stock management of prescribed medicines.
Must Do
Caxton Lodge
The registered person did not have effective arrangements in place to protect people who used the service against the risks of exposure to infection.
Must Do
The Homestead (Crowthorne) Limited
The registered person failed to protect people from the risks associated with the spread of infections.
Must Do
The Cottage Residential Home
The provider must ensure people live in an environment which protects them from the risk of cross contamination and infection.
Must Do
St Gabriel's House - Apartments
The provider must assess the risk of, prevent and control the spread of infection.
Must Do
Leopold Muller Home
Systems were not effective to ensure people were protected from infections spreading through cross contamination. This placed people at risk of harm. This was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations …
Must Do
Haversham House Limited
The provider must ensure systems are in place for effective infection prevention and control measures within the home in line with government guidance on COVID-19, and that the home is clean and maintained to enable effective cleaning.
Must Do
Haisthorpe House
People who used the service were not protected against the risk of exposure to healthcare associated infections because the provider did not operate a system to assess the risk and prevent, detect and control the spread of infection. The provider …
Must Do
Etherley Lodge
The provider must ensure the home is sufficiently clean to reduce the risk of the spread of infection, including proper segregation of dirty and clean washing in the laundry area and maintaining cleanliness in the kitchen.
Must Do
Cheshire Hair Transplant Clinic Limited
The service must ensure they have systems and processes in place to meet the requirements of The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and any other relevant guidance to reduce …
Must Do
Auckland House
The failure to assess the risk of and prevent and control the risk of the spread of infection was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Attwood's Manor Care Home
The provider must ensure that staff follow safe infection control procedures.
Must Do
Ashbourne House - Torquay
People were not protected by infection control practices. The staff and provider did not have up to date knowledge in respect of infection control practices.
Must Do
Archers Point Residential Home
The provider must ensure an effective system is in place to manage infection control, including maintaining appropriate cleanliness of premises (e.g., bedroom floors, en-suites, side tables) and equipment (e.g., wheelchairs), and documenting regular cleaning and maintenance checks for equipment.
Must Do
Charnwood
The provider had failed to ensure they were following government guidance around infection prevention and control to reduce people and staff's risk of expose to infection. The provider had failed to ensure there were effective quality assurance systems and tools …
Must Do
Baby Bump Limited
The service must assess and reduce the risk of infections. The service must ensure that there are suitable furnishings that are wipeable to reduce the risk of infection.
Must Do
Ash Court Care Centre - Camden
The registered person had not ensured that equipment used by the service was clean Regulation 15 (1) (a)
Must Do
The Cottage Residential Home
The provider must ensure people are protected from the risk of cross infection and live in a well maintained and clean environment.
Must Do
Pennsylvania House
The provider must ensure the standard of cleanliness in the kitchen is of an acceptable standard.
Must Do
Ashdale Care Home
The provider had not completed routine water maintenance. This means there is an increased risk from legionella bacteria, which can cause serious ill health.
Must Do
Worcestershire Imaging Centre
The provider should ensure hand hygiene audits are routinely carried out.
Should Do
Walnut Close
The service was did not always work within best practice guidelines for infection control. Parts of the service were in disrepair. The premises did not always meet the needs of the people using the service.
Must Do
The Spinney Nursing Home
We recommend the provider consider current guidance about managing the spread of infection.
Should Do
Sunnyside
Improvements were needed in relation to infection prevention and control and risk management and the audits in place to assess these areas had not fully identified the concerns recorded in this report.
Should Do
Standon House
Some staff were wearing nail polish and acrylic nails. This created a potential infection risk especially when supporting people with personal hygiene. One person's walking frame still had the cardboard packaging still attached. This prevented effective cleaning.
Should Do
Percys Travel
The service should ensure that vehicles are cleaned using suitable Infection, Prevention and Control (IPC) processes.
Must Do
IMB Recommendations (30)
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That wall mounted sanitisers be fitted at each of the airport HR entrances.
Home Office
Askham Grange (2021)
The arrival of pods at the beginning of the pandemic meant that no one had to share rooms and that women were kept as safe as possible. The contract for keeping the pods runs out in February 2022 and they are, we are told, to be removed from the prison. The pandemic has not gone away and the women are …
HMPPS
Swaleside (2024)
The issue of overflowing sewage from the drains must be addressed as this is exposed to the movement of food trolleys to the residential areas, which is a Health and Safety issue.
Governor / Director
Feltham (2024)
What steps are being taken to address the inconsistent cleanliness seen in the serveries, including inconsistent wearing of PPE by servery workers?
Governor / Director
Tinsley House IRC (2020)
to consider requiring the STHF to adopt a more stringent policy of compulsory facemask wearing and a more persistent approach to social distancing by detainees and staff around the centre.
Home Office
Swinfen Hall (2020)
Concerns about hygiene include: • the practice of prisoners on most wings being required to eat meals in their cells, close to a toilet (see paragraph 5.1(b)). Is there a plan to improve this? • the risk of further infestation of rats on the site, which was dangerously extensive last year (see paragraph 5.1(c)]. What mitigation measures are in place?
Governor / Director
Oakwood (2020)
Following concerns expressed in last year’s AR, the Director should consider again, how to ensure that staff enforce the use of Personal Protective Equipment (PPE) across all houseblocks and ensure the regular availability of appropriate cleaning materials so that the serveries are maintained to a more consistent standard of hygiene and cleanliness.
Governor / Director
Woodhill (2021)
To increase efforts to improve servery hygiene and maintain the food logs on each wing.
Governor / Director
Lancaster Farms (2021)
To take further steps to ensure that food hygiene logs are completed for each wing at each meal (paragraph 5.1.8).
Governor / Director
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That, in light of the experiences learned from the Covid-19 pandemic, detailed epidemic/infection control plans, with actions, are shared with the IMB GEL. This practice should be adopted in any further outbreaks of contagious illnesses.
Home Office
Gartree (2021)
Will the Governor ensure effective pest control measures are put in place, used and reviewed to control vermin?
Governor / Director
Swaleside (2022)
The Board is again concerned at the lack of discipline and cleanliness at wing serveries and believes that this should receive immediate attention. This approach should insist on the use of temperature probes and ‘whites’ to avoid a health risk to prisoners.
Governor / Director
Kent Coast Short Term Holding Facilities (STHF) (2024)
We recommend that the contractor liaises with Border Force to ensure that the cleaning contract for KIU, Manston marquees and Frontier House has consistent high levels of service.
Other
Hull (2024)
The establishment leadership have applied significant focus to tackle the vermin issues within the prison. This work needs to continue to irradicate the vermin to improve the living conditions for the prisoners.
Governor / Director
High Down (2024)
The Governor should improve hygiene standards in houseblock serveries.
Governor / Director
Lindholme (2025)
The Board asks that the Governor considers implementing a deep-cleaning programme of the in-cell toilets.
Governor / Director
Fosse Way (2025)
As identified, under point 5.1, a concern for the IMB is the catering operation at house block level. In our opinion health, safety, hygiene and food safety on individual wings, varies with no standard procedures in place. How will the Director ensure there are unified operational standards across the prison?
Governor / Director
Lancaster Farms (2022)
To take further steps to ensure that food hygiene logs are completed for each wing at each meal, and that food temperatures are routinely logged.
Governor / Director
Isis (2020)
maintain the considerable improvement in the standard of hygiene and cleanliness that has been achieved, particularly in the houseblocks (see section 5.1)
Governor / Director
East Sutton Park (2020)
To continue with the prompt and careful steps taken to combat COVID-19.
Governor / Director
Wetherby (2021)
Lengthy delays in maintenance work continue: for example, delays in repairing out of order cells and the never-ending saga of the kitchen floor. This is unacceptable. Throughout Covid the standard of cleanliness at Wetherby was excellent. However, as the pandemic seems to be easing, there is slippage. It would be unfortunate if this is allowed to continue. Can the Governor …
Governor / Director
Winchester (2022)
Given the continued impact of the vermin infestation, and the associated health and safety concerns, what more lasting and impactful arrangements can be made to resolve this issue?
Governor / Director
Wandsworth (2022)
Rodents and pigeons were a serious health risk to everyone in the establishment. Rats, either dead or alive, were an all too frequent sight. This was a serious matter and could lead to the spread of zoonotic diseases. What is being done to eliminate this problem?
Governor / Director
Isis (2023)
Will the Governor ensure that the regime allows sufficient time at the end of the day to allow cleaners to properly clean the serveries and remove any uneaten food?
Governor / Director
Oakwood (2024)
How can the Director ensure that standards during service at the serveries are consistently high (hygiene, PPE, timings, equipment working correctly)?
Governor / Director
Five Wells (2024)
What steps will be taken to improve the airflow in houseblocks?
Governor / Director
Lincoln (2025)
The Board recommends that better action is taken to address the issue of a large amount of food waste and debris outside the accommodation wings, which attracts both pigeons and vermin.
Governor / Director
Feltham (2025)
Address the inconsistent cleanliness seen in the serveries, including inconsistent wearing of personal protective equipment (PPE) by servery workers (Feltham B Governor).
Governor / Director
Gartree (2021)
Will the Prison Service ensure that the money which has been allocated to upgrade showers is ringfenced to allow this long overdue work to take place and that there is a process put in place to test for and treat legionella in all shower blocks in the future?
HMPPS
Forest Bank (2021)
Given that currently things appear to be moving in the right direction in areas such as accommodation cleanliness, general refurbishment, enhanced security, staff and resident testing and Covid containment in particular, do you think that these results will be sustainable and ongoing when the prison returns to its full capacity, bearing in mind the staff shortages you have experienced and …
Governor / Director
Detention Investigations (5)
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R41
Healthcare should agree with how cleaning must be improved and how these new standards are adopted and maintained. Healthcare facilities should be deep-cleaned at least twice yearly. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R25
Residential DCMs and wing staff should ensure that all detainees have access to cleaning products to clean their rooms, including washbasins and toilets. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R24
Residential DCMs must hold staff to account for ensuring wings are maintained at an acceptable standard cleanliness. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R23
The SMT must resolve the issue of the inadequate cleaning of the wings either by agreeing with that it will undertake the cleaning of wings or by ensuring that wing orderlies keep wings to an acceptable standard of cleanliness throughout the day, that they are properly supervised and allowed access …
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R15
Managers should closely monitor standards of cleaning throughout the centre.
Immigration Detention
PHSO Casework Decisions (30)
P-001516 — The Royal Wolverhampton NHS Trust
Mrs I complains about the care her father received from the Trust after he was admitted to hospital. She says Trust staff did not correctly follow the cross-infection guidelines which meant her father caught COVID-19 from another patient, and subsequently died.
NHS in England
Aug 2022
P-002965 — The Rotherham NHS Foundation Trust
Miss G and Mr G complain about how the Trust cared for their mother. They complain about the medication it gave her, that she was discharged when she was still unwell, about the communication with the family and that her mother caught COVID-19 despite being in a side ward.
NHS in England
Partly Upheld
Sep 2024
P-004143 — University Hospitals Sussex NHS Foundation Trust
Mr G complains about the care the Trust gave his mother between February and April 2023. He says staff treated her on an open ward where she contracted COVID-19, did not fast-track her for continuing healthcare funding despite knowing she was at the end of life, discharged her to a …
NHS in England
Oct 2025
P-001431 — A medical practice in the Nottinghamshire area
Mr O complains that infection control procedures were not properly followed when sutures covering his shoulder surgery site were removed at his GP Practice.
NHS in England
Jun 2022
P-001812 — A care home in the Sunderland area
Mrs R complains the home did not give her father good continence and personal care between April and May 2021.
NHS in England
Feb 2023
P-001981 — West Hertfordshire Hospitals NHS Trust
Mrs U complains the Trust did not help her husband to shower and he had thrush on his genital area when he was discharged to home. She also complains he caught COVID-19 during a later admission to the Trust and this caused him to have a heart attack and die.
NHS in England
May 2023
P-003846 — Nottinghamshire Healthcare NHS Foundation Trust
Mr R complains that the Trust incorrectly cleaned a wound and this led to him getting an infection and deep vein thrombosis.
NHS in England
Sep 2023
P-002638 — East Kent Hospitals University NHS Foundation Trust
Miss R complains her father died because the Trust gave him food and drink when he could not swallow after a stroke. She also complains he should have been isolated in a side room to protect him from COVID-19.
NHS in England
Partly Upheld
May 2024
P-003247 — Chesterfield Royal Hospital NHS Foundation Trust
Mr B complains his father got COVID-19 during his admission and staff did not provide treatment. He also complains about the discharge and staff not taking into account his father’s anxiety when communicating treatment plans.
NHS in England
Dec 2024
P-003401 — Manchester University NHS Foundation Trust
Ms C complains about her mother’s care and treatment in November and December 2021. She complains about poor pressure ulcer management and treatment, barrier cream products not being used and poor hygiene and personal care when dealing with her mother’s incontinence.
NHS in England
Partly Upheld
Mar 2025
P-003785 — An independent provider in the Sheffield area
Miss H complains about the organisation following hysterectomy surgery in June 2023. She says she had a post-operative haemorrhage, and then had an infection after she was discharged.
NHS in England
Aug 2025
P-003790 — Kettering General Hospital NHS Foundation Trust
Mrs I complains about care the Trust provided her sister in October and November 2021. She complains about delays in treatment, poor infection control and a lack of engagement.
NHS in England
Aug 2025
P-004033 — Kettering General Hospital NHS Foundation Trust
Mr L complained about the care Kettering General Hospital NHS Foundation Trust provided to his late father, Mr Y during a hospital admission. He complained about various aspects of care including fluid and nutritional care, care of a pressure sore, pain relief, and infection prevention control.
NHS in England
Partly Upheld
Sep 2025
P-003933 — Cambridgeshire and Peterborough NHS Foundation Trust
Miss D complains about the organisation's care of her father between September and December 2022. She complains about failures to prevent falls, getting COVID-19, to provide medication, nutritional support and to keep her father's dignity.
NHS in England
Upheld
Sep 2025
P-001456 — East Suffolk and North Essex NHS Foundation Trust
Mrs H complained about aspects of care and treatment her father, Mr T, received from the Trust in 2020. Specifically, she complained about his medication, treatment for bed sores, physiotherapy, applying a DNACPR and a delay in completing a CHC checklist.
NHS in England
Partly Upheld
Jul 2022
P-001845 — Walsall Healthcare NHS Trust
Miss E complains about how the Trust looked after her mother. She says it did not protect her from catching COVID-19 or monitor her, it failed to keep accurate records of her mother's care and its communication was poor.
NHS in England
Dec 2022
P-001652 — Medway NHS Foundation Trust
Mrs M complains the Trust did not test her mother for COVID-19 before discharging her. She also complains the Trust did not give her mother good personal or nutritional care, discharged her too soon and decided there was no treatment it could offer her.
NHS in England
Dec 2022
P-001760 — St George's University Hospitals NHS Foundation Trust
Miss B complains the Trust should have allowed her mother, Mrs P, to come home to keep her safe from COVID-19. She also complains about its basic nursing care, that it did not give Mrs P a COVID-19 vaccination, that it did not allow family to visit and support Mrs …
NHS in England
Jan 2023
P-002473 — University Hospitals of Derby and Burton NHS Foundation …
Mrs H complains the Trust did not treat a urinary tract infection properly and did a procedure although she had an infection. She also complains about her experience on the delivery ward.
NHS in England
Feb 2024
P-002585 — A practice in the Kirklees area
Mrs T complains a GP at the Practice used a contaminated swab when they did a vaginal swab test on her in December 2022.
NHS in England
Upheld
Feb 2024
P-002768 — University Hospitals of Leicester NHS Trust
Mr Y complains the Trust did not follow its Carers Charter during his mum’s hospital admission in October 2022. He also complains it did not identify his mum’s pneumonia, it wrongly decided to discharge his mum and did not communicate this decision and his mum got COVID-19 while in its …
NHS in England
Jul 2024
P-004473 — University Hospitals Birmingham NHS Foundation Trust
Mrs U complains about the following aspects of the care and treatment her sister, Ms A received from the Trust. Mrs U complains the Trust did not administer pain relief to Ms A, did not attend to Ms A's for help with her personal care in a timely manner, and …
NHS in England
Upheld
Dec 2025
P-001660 — Northern Care Alliance NHS Foundation
Miss H complains about the care the Trust gave to her mother between 8 June and 9 July 2021, when she had COVID-19 and symptoms of diarrhoea and vomiting. Miss H complains about her mother's basic care, the communication, the discharge decision and planning.
NHS in England
Dec 2022
P-001789 — The Rotherham NHS Foundation Trust
Mr E complains the Trust did not manage its COVID patients well, meaning his wife caught the virus when she was admitted.
NHS in England
Feb 2023
P-002002 — University Hospitals Birmingham NHS Foundation Trust
Mr Y complains about the care the Trust gave to his mother. He complains Mrs Y got a second infection while an inpatient at the Trust and staff did not tell him. He also complains it did not reply to his complaint.
NHS in England
May 2023
P-003472 — Walsall Healthcare NHS Trust
Miss V complains the Trust did not test her mother’s blood and failed to identify her cancer on two separate attendances in the emergency department in March 2022. She also says the Trust delayed confirming whether she had lung cancer or sarcoma until June 2022 and her mother contracted the …
NHS in England
Not Upheld
Mar 2025
P-003589 — Guy's and St Thomas' NHS Foundation Trust
Ms P complains she contracted hepatitis B from the Trust during hysterectomy surgery.
NHS in England
Jun 2025
P-004245 — Barts Health NHS Trust
Mrs V complains about Barts Health NHS Trust's care while transferring her father, Mr W, to a different hospital. She also complains that while in the care of Guy's and St Thomas' NHS Foundation Trust Mr W developed sepsis due to its poor infection control.
NHS in England
Oct 2025
P-001958 — Lancashire Teaching Hospitals NHS Foundation Trust
Mr A complains the Trust did not start compulsory COVID-19 testing for asymptomatic staff as soon as it should have. He complains his father caught COVID-19 while he was an inpatient at the Trust.
NHS in England
Not Upheld
Apr 2023
P-002565 — The Dudley Group NHS Foundation Trust
Miss R complains about the care and treatment the Trust gave her after a planned caesarean section in November 2021. She says she got an infection and sepsis.
NHS in England
Apr 2024
LGO / SPSO Decisions (73)
21-011-000 — East Anglia Care Homes Limited
Summary: Mr X complains his brother’s care home failed to tell him there was COVID-19 in the home, from which his brother died, and the care provider inappropriately contacted him about outstanding fees shortly after his death. The care home should have told Mr X his brother was at the …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-010-411 — Westward Care Limited
Summary: Mrs X complained about the COVID-19 protocols at her late mother, Mrs M’s, retirement village and the amount of time she received 1:1 care. There was no fault in the arrangements put in place by the Provider to prevent the spread of COVID-19 at the retirement village. The Provider …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-011-064 — Hallmark Care Homes (Banstead) Limited
Summary: Mrs X complained about events leading up to her husband, Mr X, contracting COVID-19 and being admitted to hospital. These matters have already been investigated by the Care Provider and the Council has also carried out a safeguarding investigation. Both identified fault and the Care Provider has taken suitable …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
22-001-027 — Four Seasons (No 9) Limited
Summary: Ms B complained on behalf of Mr & Mrs C about the care they received from Four Seasons (No 9) Ltd when it operated a care home they were both resident at; in Mrs C’s case with that care provided on behalf of the Council. We uphold the complaints, …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-004-573a — Cedars Place Care Home (21 004 573a)
Summary: Mrs B and Mrs C complained about the way the Trust cared for their late father, Mr D, when he was in hospital in December 2021 and contracted COVID-19. They also complained about the way the Council and Trust dealt with Mr D’s discharge to a care home, and …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2022
21-018-582 — Ashall Care Ltd
Summary: Mrs X complained about the short-term respite care her father, Mr Z, received at Farthings Residential Care Home which is owned by Ashall Care Ltd. The care provider has already found it failed to properly check Mr Z’s room when he moved in and did not explain how to …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
20-007-315 — HC-One Oval Limited
Summary: Mrs X complains HC-One Oval Limited’s Lyndon Hall Nursing Home failed to look after her late mother properly and failed to keep her family informed about the deterioration in her condition before she died, causing unnecessary distress. HC-One accepts Lyndon Hall failed to deal properly with two falls and …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-009-170a — The Old Hall - Spilsby Care Home (20 …
Summary: Mrs A complains about the care of her mother, Mrs B at a care home. She has also complained about a council’s safeguarding enquiries. We found fault in relation to the Home’s lack of mask wearing. We did not find fault with the other issues in this complaint.
LGO (Local Government & …
Health
Upheld
May 2022
21-000-034 — Cheshire East Council
Summary: Ms B complained on behalf of Mr & Mrs C about the care they received from Four Seasons (No 9) Ltd when it operated a care home they were both resident at; in Mrs C’s case with that care provided on behalf of the Council. We uphold the complaints, …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-014-447 — Plymouth City Council
Summary: Miss X complains about the care her grandmother, Mrs Y, received at Greenacres Care Centre, where the Council placed her for respite care. The Council accepts there were examples of poor care and poor communication with Mrs Y’s family. It needs to apologise to her family and make a …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-009-369 — North East Lincolnshire Council
Summary: Miss X complains the Council’s blanket ban on care home residents visiting people outside a care home when there were cases of COVID-19 in the care home prevented her father from visiting her on a number of occasions since September 2021. Based on the evidence seen so far, the …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-014-934 — Ebury Court Residential Home Limited
Summary: Mr X complained about the care his late mother, Mrs Z, received during the last few weeks of her life at Ebury Court Residential Home during the COVID-19 pandemic. There was no fault in the updates the Care Home provided the family, its care of Mrs Z, or how …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2022
21-016-658 — Calsa Care Limited
Summary: Mrs X complained about the visiting arrangements Calsa Care Ltd had in place during the COVID-19 pandemic, its refusal to award her essential care giver status and its decision to give her mother, Mrs M, notice. She also complained about the care Mrs M received at the end of …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
202104888 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about the care and treatment that their late parent (A) received from the board following A’s admission to hospital having suffered a stroke. A developed COVID-19 symptoms and this was confirmed by a positive swab. A’s condition deteriorated with them developing COVID-19 pneumonia and they sadly died. C …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2024
21-000-498a — Lynwood Care Centre (21 000 498a)
Summary: The Ombudsmen found no fault by a Council, a CCG and a care home in relation to the nutritional support and personal care provided to Mrs Y. We have found fault with how nutritional risk was assessed, but this did not affect the care provided and the care home …
LGO (Local Government & …
Health
Not Upheld
Jan 2022
21-004-468 — East Sussex County Council
Summary: Mr X complains the Council failed to provide transport to his son’s day centre, sent a reminder for an invoice it had not sent and expected his son to pay for services he did not receive because of COVID-19. He says this left his son without support and his …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-003-450 — Warrington Council
Summary: Mrs X complains the Council left her mother, Mrs Y, in residential care for too long, resulting in her paying too much for her care. The length of time Mrs Y spent in residential care was due to COVID-19, not fault by the Council. However, the Council failed to …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-007-453 — Birmingham City Council
Summary: There was no fault by the Council in its decision to suspend part of its pest control service during the COVID-19 pandemic. This was a decision it was entitled to take, and we have no grounds to question it. The Council’s handling of the complainant’s complaint was poor, but …
LGO (Local Government & …
Environment And Regulation
Upheld
Feb 2022
21-004-752 — Boutique Care Shepperton Ltd
Summary: Ms X complains about the care her mother, Mrs Y, received at The Burlington, a care home run by Boutique Care Shepperton Ltd. She says this resulted in having to move her mother and paying for two care homes. The Burlington’s actions contributed to the breakdown in relations between …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-000-364 — Essex County Council
Summary: Mr B complained the Council wrongly and repeatedly sent invoices to his mother, Mrs C, for care charges she did not owe, leading her to take her own life. We uphold the complaint, with the Council having acknowledged that it wrongly failed to identify Mrs C’s case as one …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-010-783 — Gloucestershire County Council
Summary: Mr S complained the Council and Trust failed to ensure his father, Mr F, was properly discharged from hospital into residential care. He also complained the Council failed to assess Mr F’s care and support needs. We have found fault in the actions of both organisations. We recommended financial …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-013-739 — Lancashire County Council
Summary: Mr X complains the Council failed to deal properly with Mrs Y’s move to Aadamson House Care Home, where she received inadequate care. The Council has apologised for the way it dealt with Mrs Y’s move to the Care Home. It also accepts the care she received there put …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-012-996 — Stonehaven (Healthcare) Ltd
Summary: Mrs N complained about the actions of Stonehaven Healthcare Ltd in relation to its care of her uncle, Mr X, during the COVID-19 pandemic. The Care Provider was at fault when it gave Mr X notice without first exploring alternative options. This caused Mr X uncertainty about whether the …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-000-741 — Barchester Healthcare Homes Limited
Summary: Mrs J complained about the care her mother received while she was resident at Meadowbeck Care Home operated by the Care Provider. Among other matters, Mrs J complained she had only very limited opportunity to visit her mother before she died of COVID-19 in May 2020. We uphold the …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
22-000-692 — Lancashire County Council
Summary: Ms X complains the Council failed to deal properly with her financial assessment by failing to respond to telephone communications and correspondence, and by failing to make reasonable adjustments to reflect her needs, resulting in it imposing charges which she could not afford to pay and taking 10 months …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
24-014-250 — London Borough of Wandsworth
Summary: Mrs X complained the Council failed to act when she contacted it with concerns about her late brother’s care and it was difficult to get in contact with anyone. She also complained the care home the Council commissioned failed to get an air mattress for her late brother before …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
201004951 — Fife NHS Board
Mrs A was admitted to hospital on numerous occasions in the two years before her death. She had a complex medical history and tested positive for a bacterial infection, Methicillin-resistant Staphylococcus aureus (MRSA), on six occasions during that time. Mrs A's daughter (Mrs C) complained that the board failed to …
SPSO (Scottish Public Se…
Health
Not Upheld
Aug 2012
201708720 — Lothian NHS Board - Acute Division
Mrs C complained about the care her mother (Mrs A) received at St John's Hospital. Mrs C complained about the number of ward moves that Mrs A experienced. Mrs A had dementia and Mrs C said that the number of ward moves caused Mrs A to become disorientated. Mrs C …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2018
20-006-183 — Coventry City Council
Summary: Mr D complains the Council’s adult social care team failed to help him deal with his council tax benefits or to get food during the first coronavirus lockdown in 2020. The Council did not send Mr D a copy of his care and support assessment, but this did not …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
20-010-131 — Sandwell Metropolitan Borough Council
Summary: Miss X said the Council failed to investigate her complaint about the smell caused by clinical waste bins from a neighbouring care home. We have seen nothing to indicate the Council knew about Miss X’s concerns before she complained to the Ombudsman. The Council was not at fault. However, …
LGO (Local Government & …
Environment And Regulation
Upheld
Jan 2022
21-007-248 — Warwickshire County Council
Summary: Mrs X complains the Council failed to deal properly with the family’s request for a discretionary 12-week property disregard for her mother-in-law. The Council failed to explain the reasons for not granting a discretionary 12-week property disregard. This creates doubt over whether it made the right decision. To remove …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
20-012-246 — Hampshire County Council
Summary: Mr X complained about the care received by his father, Mr F, when he was at Ashley Lodge Care Home. The Care Provider and Council have already admitted some of the record-keeping was poor. The Council should ensure staff at the Care Home are reminded of the importance of …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-001-705 — West Sussex County Council
Summary: Ms X complained the Council failed to provide adequate support for her daughter, Miss D. She also complained the Council stopped Miss D’s direct payments in February 2020 and November 2020 for no good reason and refused to reimburse her for activities and items she had bought on behalf …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-003-087 — West Northamptonshire Council
Summary: Ms X complained the Council failed to ensure her son, Mr Z, received appropriate care, and also failed to complete his mental capacity assessment and care and support reassessment. The Council was not at fault in relation to these matters. However, it is at fault for delaying in making …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-006-662 — Newcastle upon Tyne City Council
Summary: The Council failed to provide Mr X with the support he needed to complete assessment forms for disability related expenditure and then communicated poorly about this with Mr X’s representative. The Council has apologised for the faults and agreed to consider backdating any allowance for disability related expenditure it …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-012-935 — Sefton Metropolitan Borough Council
Summary: Dr X complains the Council has failed to provide her daughter with the support she has been assessed as needing. The Council has failed to meet all her daughter’s needs, causing avoidable distress. The Council needs to apologise, involve Dr X in assessing her daughter’s needs and pay financial …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-010-265 — Cheshire West & Chester Council
Summary: Mrs X complains about the charges for her son’s care after he left a care home to live with his family because of COVID-19. Although the Council agreed to waive 50% of the charge, Mrs X says this left her son without enough money to contribute towards the family’s …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-006-872 — London Borough of Brent
Summary: Dr X complains the Council failed to deal properly with his late father’s care needs from May to November 2020, at times failing to meet them and causing unnecessary distress. The Council did not fail to meet the father’s needs. However, it caused avoidable distress by failing to respond …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-016-909 — Tameside Metropolitan Borough Council
Summary: Mr X complains the Council failed to deal properly with the charges for his mother’s care,
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-012-231 — Cornwall Council
Summary: Mrs X complains the Council has failed to meet her daughter’s assessed need to attend day services since they were allowed to reopen in 2020, which has caused her avoidable distress. The Council delayed in reviewing her daughter’s needs, then failed to review them properly and provided misleading and …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
20-014-148 — Stockport Metropolitan Borough Council
Summary: We have upheld complaints from Ms D, Ms K and Ms F about the actions of the Council, Home and Integrated Care Board in connection with the care of their late mother, Mrs M.
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-019-063 — Shropshire Council
Summary: We found no fault by a Council and ICB with regards to how they assessed Mrs Y’s needs following her discharge from hospital. However, we found fault with the Council’s complaint response which incorrectly advised Mrs Y’s son that a Continuing Healthcare Checklist had been completed when it had …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-009-880 — Hertfordshire County Council
Summary: Mr A complained professionals from a Council and Trust inappropriately interfered with his wife’s package of care when she left hospital in April 2021. We found fault in how professionals worked out what was in Mrs A’s best interests. However, on balance, this did not lead to an injustice.
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
21-018-733 — Methodist Homes
Summary: Ms X complained the Care Provider refused to award her essential care giver status, lied about her to her siblings, made her carry out her COVID-19 lateral flow tests on site and failed to deal appropriately with her complaints. She says this caused her and her mother distress. There …
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2022
22-003-541 — Cambridgeshire County Council
Summary: Mr X complained about Cambridgeshire and Peterborough NHS Foundation Trust (the Trust) and Cambridgeshire County Council (the Council). He complained about faults in his discharge from hospital, reablement, and referrals for community therapy services. He also complained about the Council’s complaint handling. We have upheld parts of the complaint …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
24-009-211b — Spencer Grove Care Home (24 009 211b)
Summary: Mrs A complains about the way the Care Home and GP Practice cared for her mother, Mrs B. We will not investigate this complaint because we are unlikely to achieve anything more. This is because the coroner has already looked at the issues, and there has already been an …
LGO (Local Government & …
Adult Care Services
Nov 2024
24-009-211 — Milford Care Limited
Summary: Mrs A complains about the way the Care Home and GP Practice cared for her mother, Mrs B. We will not investigate this complaint because we are unlikely to achieve anything more. This is because the coroner has already looked at the issues, and there has already been an …
LGO (Local Government & …
Adult Care Services
Nov 2024
201102400 — Highland NHS Board
Mrs C was admitted to hospital for a gastroscopy (a procedure in which a thin, flexible tube is used to look inside the stomach) under general anaesthetic. She waited in the day room until she was allocated a bed. During this time a member of staff discussed confidential information with …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2012
201400264 — Highland NHS Board
Ms C, an advocate, complained on behalf of her client (Mr A) about the infection control procedures used by Raigmore Hospital when he had a total hip replacement. When Mr A attended the pre-operative assessment when he was first scheduled for surgery, it was found that he had an in-growing …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2015
202104334 — Lothian NHS Board - Acute Division
C complained about the care and treatment their late parent (A) received. A had a diagnosis of small cell lung cancer and was transferred to the Western General Hospital for urgent treatment of metastatic lung cancer. This was during the first year of the COVID-19 pandemic. Shortly after A's admission, …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2022